Background: Despite growing interest in cardio-oncology rehabilitation (CORE), data on cardiopulmonary exercise testing (CPX/CPET) in Japanese cancer patients remain scarce.

Methods and Results: We reviewed 440 CPX examinations at Toranomon Hospital (2018–2023) and identified 37 tests from 28 patients with active cancer and cardiovascular problems. CPX parameters included peak oxygen uptake (peak V̇O₂), anaerobic threshold (AT), ventilatory efficiency (V̇E vs. V̇CO₂slope), and metabolic equivalents (METs). Patients were classified into those with cancer therapy-related cardiac dysfunction (CTRCD or subclinical CTRCD) and those without. Various anticancer agents had been used, with anthracycline exposure more frequent in the CTRCD group. No patient received rehabilitation before CPX. Median age was 60 years; 68% female. Cancers included breast (n=17), lymphoma (n=5), leukemia (n=3), and others. Cardiovascular problems comprised CTRCD/subclinical CTRCD (n=15), ischemic heart disease (n=2), and others. Median peak V̇O₂was 14.7 mL/kg/min (63% predicted), with 43% below the prognostic threshold of 14 mL/kg/min. Median AT was 10.9 mL/kg/min and V̇E vs. V̇CO₂slope 30.7, indicating reduced cardiorespiratory function. No significant differences were observed between the CTRCD and non-CTRCD groups. In 4 patients with serial CPX, exercise capacity changes did not always parallel left ventricular ejection fraction.

Conclusions: In cancer patients with cardiovascular problems, CPX revealed reduced exercise tolerance beyond cardiac function. These findings highlight the need for individualized rehabilitation inform future CORE protocols.

Background: Periprocedural myocardial injury (PMI) is a common complication of percutaneous coronary intervention (PCI). Elevated post-PCI index of microcirculatory resistance (IMR) has been linked to PMI. The angiography-derived IMR (angio-IMR) serves as a pressure-wire-free method to assess coronary microvascular function. This study aimed to establish the association between post-PCI angio-IMR and PMI.

Methods and Results: We retrospectively analyzed 101 consecutive elective PCI cases where PMI diagnosis and post-PCI angio-IMR calculation were feasible. Angio-IMR was computed using computational flow and pressure simulations. Patients were categorized into 2 groups based on PMI status: PMI (n=33), and non-PMI (n=68). The PMI group had significantly higher post-PCI angio-IMR values than the non-PMI group (31.8±5.9 vs. 23.8±6.0; P<0.001). Both univariate and multivariate logistic regression analyses revealed an association between post-PCI angio-IMR and PMI. Patients with post-PCI angio-IMR ≥29 had a significantly higher incidence of PMI (67.6% vs. 12.5%; P<0.001).

Conclusions: Increased post-PCI angio-IMR values were strongly associated with PMI. Post-PCI angio-IMR might serve as a useful non-invasive predictive of PMI following elective PCI.

Background: The relationship between the reduction in aortic valve pressure gradient (AVG) after transcatheter aortic valve implantation (TAVI) and improvements in left ventricular ejection fraction (LVEF) or long-term survival remains unclear.

Methods and Results: We retrospectively analyzed 121 patients with aortic stenosis (AS) and LVEF <50% who underwent TAVI. Transthoracic echocardiography (TTE) was performed before and after TAVI, and the difference in mean AVG was defined as delta-AVG. LVEF improvement was defined as a ≥10% increase from baseline at 1 year. Among 82 patients with 1-year TTE evaluation, LVEF improvement was observed in 37 (45.1%) patients. A higher delta-AVG was identified as an independent predictor of LVEF improvement (odds ratio 1.04; 95% confidence interval [CI] 1.01–1.07; P=0.002), and receiver operating characteristic analysis indicated the optimal cut-off was 20.5 mmHg (sensitivity 48.9%; specificity 89.2%; area under curve 0.723; P=0.002). During a mean follow up of 1,042.6±577.5 days, 5 cardiac deaths occurred. Cox proportional hazards analysis revealed that a low delta-AVG was identified as an independent predictor of cardiac death (hazard ratio 0.91; 95% CI 0.7–0.99; P=0.023). Additionally, a greater delta-AVG was significantly associated with a larger increase in delta-stroke volume between post-TAVI to 1 year (r=0.255; P=0.021).

Conclusions: In patients with severe AS and reduced LVEF, delta-AVG could be a novel predictor of 1-year LVEF improvement and long-term survival after TAVI.

Background: Early detection of heart failure (HF) relies on community-based interventions supported by seamless coordination. In this study, we examined the challenges and opportunities in developing HF support system, drawing on hospital-led community collaboration activities and a participant survey.

Methods and Results: A cross-sectional survey of 31 participants in a regional multidisciplinary meeting yielded 13 responses (41.9%). Non-medical professionals demonstrated lower baseline knowledge but higher satisfaction and learning effectiveness. Principal component analysis revealed occupational differences.

Conclusions: Foundational education was effective, particularly for non-medical professionals, and highlighted the need to address disparities in knowledge and tool utilization.

Background: Day-to-day home blood pressure variability (BPV) is associated with cardiovascular risk and influenced by environmental conditions. However, it is unclear whether short-term increases in day-to-day BPV can be predicted from personal sensor data. In this study, our aim is to develop and validate a machine-learning prediction model for short-term increases in day-to-day BPV using personal sensor data on behavioral and environmental exposure.

Methods and Results: We will conduct a 30-day monitoring study in community-dwelling adults. Participants will measure home BP twice daily, while a portable sensor and an activity tracker record environmental conditions and physical activity. The primary outcome is an episode of increased systolic day-to-day BPV, defined as a rolling 5-day coefficient of variation ≥11.0%. Candidate predictors will be derived from the preceding 5-day exposure window. We will construct window-level data, allocate participants to training and test sets, and train machine-learning models with participant-level cross-validation. We will evaluate performance using the area under the receiver operating characteristic curve, calibration, Brier score, and decision-curve analysis, and interpret the XGBoost model with Shapley additive explanations to quantify the predictor contributions.

Conclusions: This protocol outlines a framework for predicting short-term increases in day-to-day BPV from personally experienced environmental exposure and behaviors, supporting future personalized interventions targeting modifiable environmental and behavioral factors.

Background: The clinical differences between intra-aortic balloon pumping (IABP) and a microaxial flow pump (Impella) for left ventricular (LV) unloading in patients with fulminant myocarditis (FM) supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) remain unclear.

Methods and Results: In this single-center, retrospective cohort study, we analyzed 27 consecutive patients with lymphocytic FM who received VA-ECMO support. Patients were stratified by the LV unloading device that was used: IABP (n=15); or Impella (n=12). The primary endpoint was a composite of all-cause mortality or implantation of an extracorporeal ventricular assist device (exVAD) within 30 days of VA-ECMO initiation. Temporal changes in laboratory and hemodynamic parameters during the first 7 days of support were also assessed. Baseline characteristics, including LV ejection fraction (IABP 16% vs. Impella 18%; P=0.814) and QRS duration (139 vs. 105 ms; P=0.805), were comparable between groups. Nine patients met the primary endpoint (mortality [n=7]; exVAD implantation [n=2]). Kaplan-Meier analysis revealed a significantly lower incidence of the primary endpoint in the Impella group (log-rank P=0.018). The Impella group also showed a significantly greater improvement in cardiac power output (group×time interaction, P=0.040). Hemolysis, elevated total bilirubin, and increased serum creatinine were more pronounced in the Impella group.

Conclusions: In patients with FM requiring VA-ECMO, LV unloading with Impella was associated with improved short-term clinical outcomes compared with IABP.

Background: The original cardiovascular–kidney–metabolic (CKM) staging system uniformly categorized all individuals with type 2 diabetes (T2D) as Stage 2. We aimed to improve the prognostic accuracy for chronic kidney disease (CKD) progression by incorporating the Kidney Disease: Improving Global Outcomes risk categories – based on estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) – into CKM Stage 2.

Methods and Results: This study included 600 individuals with T2D from Kure Medical Center and Chugoku Cancer Center. The primary outcome was CKD progression, defined as a ≥30% decline in eGFR. The refined system significantly improved risk stratification for CKD progression compared with the original system, showing a higher area under the receiver operating characteristic curve and greater integrated discrimination improvement. The risk of CKD progression, reflected by hazard ratios derived from the Fine–Gray subdistribution hazard models, increased progressively across the refined CKM stages after adjustment for potential confounders, including baseline eGFR. However, the independent prognostic value of the refined system was attenuated when baseline UACR was additionally included in the model.

Conclusions: Integrating eGFR and UACR into the original CKM staging system enhances the prognostic performance for CKD progression in individuals with T2D. This refined system, incorporating these renal biomarkers, provides superior risk stratification compared with the original system, and serves as a more robust tool for clinical prognostic assessment.

Background: Falls are a serious medical problem. With the aging of patients with cardiovascular disease (CVD), falls have become an important clinical outcome. However, evidence regarding falls in this population is limited, and the impact of cardiac rehabilitation (CR) remains unclear. This study investigated the incidence of falls and examined the association between outpatient CR (OCR) and falls among older patients with CVD.

Methods and Results: This single-center prospective cohort study included 110 patients with CVD aged ≥65 years who participated in early phase II CR (mean age 77±6 years; 36% women). The occurrence and frequency of falls within 1 year of discharge were assessed using a mailed self-reported questionnaire. Participants were divided into non-OCR and OCR groups. The overall incidence rate of falls was 20.9%. The non-OCR group had a significantly higher occurrence and frequency of falls than the OCR group. Negative binomial and modified Poisson regression analyses demonstrated that OCR participation was significantly associated with a lower fall rate (adjusted incidence rate ratio 0.42; 95% confidence interval [CI] 0.23–0.76; P<0.01) and risk (adjusted risk ratio 0.39; 95% CI 0.18–0.89; P=0.02).

Conclusions: Among older patients with CVD, approximately 20% experienced a fall within 1 year after hospital discharge. Patients who participated in the OCR program had significantly lower fall rates and risks.

Background: Drug-coated balloon (DCB) is a novel treatment option for percutaneous coronary intervention (PCI). The presence of heart failure (HF) in patients with coronary artery disease (CAD) is associated with a poor prognosis. However, the clinical significance of DCB-based PCI in CAD patients with HF is unknown.

Methods and Results: This was a retrospective analysis of a cohort study from a prospective, single center registry from 2015 to 2024. We enrolled 258 CAD patients with chronic HF who underwent PCI with DCB or in combination with a drug-eluting stent (DES). Propensity score matching analysis was performed between the DCB-based PCI and DES-only PCI groups. The primary endpoint of this study was all-cause mortality. Baseline clinical characteristics were comparable between the groups. The total DES number and length were significantly reduced in patients with DCB-based PCI than in those with DES-only PCI. Kaplan-Meier analysis revealed that the DCB-based PCI group had a significantly lower rate of all-cause mortality compared with the DES-only group (log-rank test, P=0.04).

Conclusions: In CAD patients with chronic HF, DCB-based PCI was associated with a lower risk of mortality compared with DES-only PCI.

Background: The prognosis of acute myocarditis (AM) is difficult to predict due to its variable presentation. We investigated the prognosticators of AM patients requiring hospitalization.

Methods and Results: We conducted a multicenter observational study including 80 hospitalized AM patients. The primary endpoint was a composite of all-cause death, heart transplantation, and implantation of ventricular assist devices during the index hospitalization. Thirteen (16%) patients reached the endpoint. Longer QRS duration at admission independently predicted adverse outcomes, with an optimal cut-off of 130 ms.

Conclusions: Prolonged QRS duration at admission might predict in-hospital prognosis in AM patients regardless of whether or not it was fulminant.

Background: Drug-coated balloon (DCB) angioplasty has shown short-term feasibility for large-vessel coronary artery disease (CAD; ≥3 mm); however, long-term outcomes remain unclear. This study aimed to evaluate the 5-year cardiovascular outcomes of DCB angioplasty vs. drug-eluting stents (DES) for de novo large-vessel CAD.

Methods and Results: This single-center retrospective study analyzed patients undergoing percutaneous coronary intervention (PCI) with either DCB (SeQuent Please) or DES (Xience Alpine) between January 2016 and December 2018. The primary outcomes were cardiovascular events (CVE), defined as a composite of cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR). Secondary outcomes included minimal lumen diameter (MLD), diameter stenosis (DS), and late lumen loss (LLL), assessed at the index PCI and at the 1-year angiographic follow up. Overall, 114 patients (122 lesions) in the DCB group and 269 patients (293 lesions) in the DES group were analyzed, with similar median follow-up durations (1,678 vs. 1,825 days; P=0.687). At 5 years, TLR and CVE rates were comparable between the DCB and DES groups (7.9% vs. 4.5%, P=0.239; and 11.4% vs. 10.4%, P=0.773, respectively). No significant differences in MLD, DS, or LLL were observed between the groups at the 1-year follow up.

Conclusions: With careful lesion selection and preparation, DCB angioplasty could serve as a feasible treatment option for de novo large-vessel CAD in clinical practice.

Background: Postoperative atrial fibrillation (POAF) after cardiac surgery requires prompt intervention. We compared landiolol with verapamil for POAF treatment.

Methods and Results: This randomized trial enrolled 179 patients; 45 developed POAF. Landiolol achieved higher sinus rhythm conversion at 8 h (73.3% vs 16.7%; P=0.0016), but not at 12 h. No differences were observed in recurrence, adverse events, or intensive care unit stay.

Conclusions: Landiolol facilitates earlier rhythm conversion without clear short-term clinical benefit.

Background: The Kumamoto criteria are proposed for predicting ^{99 m}Tc-pyrophosphate (PYP) uptake, but real-world performance is uncertain.

Methods and Results: We reviewed 102 consecutive patients who underwent PYP scintigraphy; grade ≥2 was positive, and grade 1 equivocal/negative. Of them, 15 were positive; 11 had scores 0–1 yet were positive, while 8 scored 2 and yet were negative. Adding age, sex, PR interval, and atrial fibrillation improved the area under the curve (AUC) from 0.598 to 0.866; excluding sex yielded AUC 0.842.

Conclusions: Using the Kumamoto criteria alone showed limited discrimination; combining routine variables may help select patients for PYP scintigraphy.

Background: Postoperative declines in activities of daily living (ADL) are concerning in older adults undergoing cardiovascular surgeries. Sarcopenia represents a determinant of such adverse outcomes. We examined whether preoperative sarcopenia and its components predicted postoperative ADL decline in older patients who underwent elective cardiovascular surgeries.

Methods and Results: This retrospective cohort study included 589 patients aged ≥65 years who underwent elective coronary artery bypass grafting, heart valve surgery, or thoracic aortic surgery. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 criteria. ADLs were assessed using the Barthel Index, with in-hospital ADL decline being defined as a ≥10-point reduction. Thirty-three (5.6%) patients had sarcopenia preoperatively. ADL decline was significantly higher in the patients with sarcopenia compared with those without (15.2% vs. 5.0%; P=0.014). Multivariable logistic regression analyses demonstrated that sarcopenia was independently associated with ADL decline (odds ratio 3.094; 95% confidence interval 1.067–8.968; P=0.038). Each sarcopenia component – low muscle mass, low muscle strength, and slow gait speed – was also independently associated with ADL decline (all P<0.050). Age-adjusted receiver operating characteristic analyses showed that sarcopenia demonstrated moderate discrimination for predicting postoperative ADL decline, with an area under the curve of 0.707.

Conclusions: Preoperative sarcopenia and its individual components independently predicted in-hospital ADL decline following cardiovascular surgery. Preoperative assessments may help identify high-risk patients.

Background: Because snowfall may affect the acute outcomes of severe cardiovascular diseases by prolonging emergency medical service (EMS) response times, we investigated the association between snowfall and EMS response times for out-of-hospital cardiac arrests (OHCAs) in the regions of Japan.

Methods and Results: We used the Utstein database, a nationwide population-based registry that collects data on all OHCA patients in Japan, during winter from 2009 to 2019. A prefecture-specific logistic regression model was applied to estimate odds ratios (ORs) of prolongation of EMS response time (≥7 min), which was associated with poorer neurological outcomes, on days with moderate/heavy snowfall compared to no-snowfall days. A random-effects meta-analysis model was applied to obtain pooled ORs in both overall and subgroup analyses (“heavy snowfall prefectures” and “non-heavy snowfall prefectures”). Among 94,428 bystander-witnessed cardiogenic OHCA patients, the ORs of prolonged EMS response time were 1.05 (95% confidence interval (CI): 0.96, 1.14) on moderate snowfall days and 1.22 (95% CI: 1.07, 1.40) on heavy snowfall days, compared to no-snowfall days. Subgroup analysis revealed no statistical difference between heavy snowfall prefectures and non-heavy snowfall prefectures, although ORs were higher for heavy snowfall prefectures.

Conclusions: Snowfall prolongs EMS response time to cardiogenic OHCA in both areas with heavy snowfall and those with less snowfall, which may also impact survival and neurological outcomes.

Background: The clinical impact of left QRS axis deviation (LAD) during new-onset left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) remains unclear.

Methods and Results: This single-center retrospective study analyzed 254 patients who developed new-onset LBBB during hospitalization after TAVR. Clinical and echocardiographic outcomes were compared between patients with LBBB and LAD (LBBB_LAD) and those with LBBB and a normal QRS axis (LBBB_NA). 96 patients (38%) had LBBB_LAD, defined as a QRS axis <−30°. A more leftward preprocedural QRS axis independently predicted LBBB_LAD(odds ratio 1.20 per 10° decrement; 95% confidence interval (CI) 1.09–1.33; P<0.01). At 3 years, there were no significant differences between groups in all-cause death (28% vs. 19%; P=0.14), cardiovascular death (6% vs. 5%; P=0.73), or heart failure rehospitalization (18% vs. 10%; P=0.07). However, LBBB_LADwas associated with a higher incidence of permanent pacemaker implantation (PPI) for atrioventricular conduction disorder (16% vs. 6%; P=0.02) and remained an independent predictor of PPI (Cox hazard ratio 2.46; 95% CI 1.06–5.73; P=0.04). Echocardiographic measures, including left ventricular ejection fraction, chamber size, and mitral regurgitation severity showed no significant longitudinal differences between groups.

Conclusions: Compared to post-TAVR LBBB_NA, post-TAVR LBBB_LADis associated with an increased need for PPI, but not with adverse mortality or heart failure outcomes at 3-year follow-up. Closer and extended rhythm monitoring may be warranted in this subgroup.

Background: Renal dysfunction (RD) is common at admission for acute heart failure (AHF), but there is limited evidence focusing on older adults and considering the influence of physical function. We evaluated the prognostic significance of admission RD severity as a risk factor for adverse outcomes in older patients with AHF, while considering the potential modifying effect of physical function.

Methods and Results: This multicenter prospective cohort study enrolled 710 patients aged ≥65 years with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². Admission RD was stratified into 4 severity classes: mild RD (eGFR 45–59), moderate RD (eGFR 30–44), severe RD (eGFR 15–29), and kidney failure (eGFR <15). The primary outcome was a composite of HF readmission and all-cause death within 1 year post-discharge. Subgroup analyses assessed potential effect modification by physical function and other variables. After multivariable adjustment, severe RD or kidney failure was significantly associated with a higher risk of the composite outcome compared with mild RD (adjusted hazard ratio: 1.529; 95% confidence interval: 1.005–2.326). A possible interaction was observed between moderate RD and the Short Physical Performance Battery score at discharge (P for interaction=0.093).

Conclusions: Severe RD or kidney failure at admission independently predicted 1-year HF readmission and all-cause death. In moderate RD, physical function may modify RD prognostic impact.

Background: Data on the clinical outcomes and hemodynamic performance of the smallest commercially available bioprostheses (19 mm) in Japan for aortic valve replacement (AVR) remain limited.

Methods and Results: We analyzed the data of 187 adults (median age, 76 [interquartile range (IQR): 73–80] years; 165 women [88%]; median follow-up, 65 [IQR: 32–95] months) with symptomatic aortic valve stenosis, regurgitation, and valve deterioration who underwent surgical AVR between January 2015 and July 2024 with the Avalus (n=7), Magna (n=77), Epic (n=26), Inspiris (n=58), or Mosaic (n=27) bioprosthesis because of having small aortic annuli. The primary and secondary endpoints were all-cause death and major adverse cardiac events, respectively. Moderate-to-severe prosthesis-patient mismatch occurred in 53 patients (28%). The overall survival rates (95% confidence interval [CI]) at 1, 3, and 5 years after valve replacement were 93.0% (88.3–95.9%), 87.0% (81.0–91.2%), and 85.7% (79.5–90.1%), respectively. The rates of freedom from major adverse cardiac and cerebrovascular events (95% CI) at 1, 3, and 5 years were 96.2% (92.1–98.2%), 90.2(84.5–93.9%), and 88.7(82.5–92.7%), respectively. Four patients required re-intervention (3, re-AVR and 1, medication). No significant differences were observed in either outcomes or hemodynamics among the different aortic bioprostheses.

Conclusions: Surgical replacement with 19-mm third-generation aortic valve bioprostheses for small aortic annuli is feasible with favorable early and mid-term hemodynamics.

Background: Non-small cell lung cancer (NSCLC) is associated with a high risk of venous thromboembolism (VTE). However, data on specific risk factors for VTE in patients with advanced NSCLC remain limited.

Methods and Results: Using a Japanese nationwide administrative database, we analyzed 20,206 patients aged ≥18 years with advanced NSCLC who received first-line chemotherapy between January 2016 and January 2023. VTE events were identified through International Classification of Diseases, Tenth Revision codes and imaging studies. Risk factors were evaluated using Cox proportional hazards models with time-dependent covariates. The cumulative incidence of VTE was 4.2% and 6.1% at 365 and 730 days after the first date of chemotherapy for NSCLC, respectively. Several significant risk factors for VTE were identified, including female sex (hazard ratio [HR] 1.374; 95% confidence interval [CI] 1.157–1.631), higher body mass index (HR 1.029 per 1-kg/m²increase; 95% CI 1.009–1.048), previous VTE (HR 2.707; 95% CI 1.907–3.843), platinum-based chemotherapy (HR 1.217; 95% CI 1.051–1.410), anti-vascular endothelial growth factor agent (HR 1.763; 95% CI 1.458–2.132), heart failure (HR 1.677; 95% CI 1.432–1.965), and stroke/transient ischemic attack (HR 1.296; 95% CI 1.055–1.593).

Conclusions: This large-scale study identified several significant risk factors for VTE in patients with advanced NSCLC. The findings suggest the need for risk-stratified monitoring and prophylactic strategies to reduce VTE-related complications in high-risk patients.

Background: In patients at high bleeding risk (HBR), short dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) reduces bleeding without increasing ischemic events. However, the sex-based differences in the effects of short DAPT strategy followed by prasugrel monotherapy compared with conventional DAPT strategy remain unclear.

Methods and Results: The 24-month outcomes from 2 multicenter, non-interventional, prospective registries, PENDULUM mono (n=872; short DAPT strategy followed by prasugrel monotherapy) and an HBR subset of the PENDULUM registry (n=1,553; conventional DAPT strategy), were analyzed using the inverse probability of treatment weighting method. Primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE) and clinically relevant bleeding (CRB: Bleeding Academic Research Consortium [BARC] types 2, 3, and 5). In women, short DAPT strategy was associated with numerically lower rates of MACCE (8.2% vs. 12.3%; hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.42–1.20; P=0.197) and CRB (4.7% vs. 7.0%; HR 0.68, 95% CI 0.35–1.32; P=0.258). In men, similar trends were observed for MACCE (8.8% vs. 11.0%; HR 0.86, 95% CI 0.62–1.21; P=0.388) and CRB (7.0% vs. 8.1%; HR 0.87, 95% CI 0.60–1.26; P=0.460). No significant interaction between treatment and sex was found for MACCE (P=0.599) or CRB (P=0.537).

Conclusions: In HBR patients undergoing PCI, a short DAPT strategy followed by prasugrel monotherapy had numerically fewer ischemic and bleeding events than conventional DAPT strategy, without evidence of sex-based heterogeneity.

Background: The associations between symptom characteristics and patients’ interpretations and sources of knowledge about acute coronary syndrome (ACS) remains unclear.

Methods and Results: We enrolled 81 patients with ACS. Patients who misinterpreted their symptoms more frequently reported atypical features such as tenderness (13.3% vs 0%; P=0.028) and syncope (11.8% vs 0%; P=0.011). Common knowledge sources among patients who correctly interpreted their symptoms included television, healthcare professionals, and the internet without social media.

Conclusions: Patients experiencing atypical symptoms often misinterpret them. Most knowledge sources for those who interpreted correctly were traditional.

Background: The Japanese Resuscitation Council’s 2020 Guidelines recommend transmitting a prehospital 12-lead electrocardiogram (PH-ECG) for adult patients suspected of having ST-elevation myocardial infarction (STEMI). Nationwide, the primary methods of ECG transmission are either prefecture-specific emergency transport systems or cloud-based services. However, prefectural systems often lack convenience, while cloud-based services are associated with substantial implementation costs.

Methods and Results: A smartphone application (JOIN^®), which enables ambulance information-sharing with receiving hospital physicians, has been widely adopted across Japan. Leveraging its photo function to transmit ECGs, we initiated prehospital ECG transmission from ambulances without incurring additional costs. Over the past year, the system has been utilized in approximately 20 cases at our hospital. Analysis of transport times by shift period (weekday daytime vs. non-shift hours [weekday nighttime and weekends/holidays]) revealed no significant difference during daytime shifts. However, during non-shift hours, the ECG transmission group demonstrated a tendency for shorter door-to-catheterization laboratory time (25±5.0 vs. 51±18 min).

Conclusions: Obtaining a 12-lead ECG prior to hospital arrival reduces waiting times for catheter-based treatment. When ambulances and receiving hospitals are connected via a smartphone application, the photo function can facilitate prehospital ECG transmission without additional implementation costs. This approach may represent a novel strategy to improve outcomes for STEMI patients.

Background: Percutaneous coronary intervention (PCI) for calcified coronary lesions without stent implantation remains a challenging therapeutic strategy. The efficacy of drug-coated balloon (DCB) therapy in relation to specific calcified plaque morphologies has not been previously investigated.

Methods and Results: We conducted a retrospective analysis of 150 lesions (136 patients) who underwent optical coherence tomography (OCT)-guided PCI using DCB for angiographically moderate-to-severe calcified lesions. Based on the OCT findings, target lesions were categorized into 3 groups: superficial calcific sheet (SC) group; calcific protrusion (CP) group; and eruptive calcified nodule (eCN) group. Long-term clinical outcomes, including clinically driven target lesion revascularization (CD-TLR), myocardial infarction (MI), cardiac death, and the composite endpoint of major adverse cardiovascular events (MACE), were assessed over a median follow up of 2.6 years. No significant differences in rates of CD-TLR, MI, cardiac death, or MACE were observed between the SC and CP groups. In contrast, the eCN group showed significantly higher incidences of MI (P<0.01 vs. SC; P<0.05 vs. CP), cardiac death (P<0.01 vs. SC and CP), and MACE (P<0.01 vs. SC and CP) compared with the other 2 groups.

Conclusions: In moderate-to-severe calcified lesions where adequate vessel preparation was achieved, DCB therapy was associated with favorable outcomes in lesions with SC or CP morphologies. In contrast, lesions involving eCN were linked to significantly worse clinical outcomes.

Background: Trans-subclavian access transcatheter aortic valve implantation (TAVI), typically from the left side, is feasible. However, right subclavian artery access is technically challenging because of the anatomical orientation, resulting in malalignment of the transcatheter heart valve within the aortic annular plane.

Methods and Results: We aimed to evaluate procedural outcomes, device–annulus alignment, and clinical efficacy of right trans-subclavian (RtTS) TAVI. Of a consecutive 423 patients who underwent TAVI, 32 cases performed via right and left subclavian access were analyzed. Implanted device depth and angle were analyzed angiographically. The device–annulus angle was measured angiographically. Fifteen of 22 patients were treated with a balloon-expandable valve, and 7 patients received a self-expanding valve, via RtTS. Procedural success was achieved in all cases. Compared with femoral and left subclavian approaches, RtTS led to a significantly larger device–annulus angle (6.0° vs. 8.7°; P<0.05), with deep left coronary cusp implantation (2.4 vs. 4.4 mm; P=0.05). Post-procedural transcatheter heart valve function was comparable across the groups, and no patients had greater than moderate paravalvular leakage. However, the incidence of symptomatic stroke occurred in 2 patients in the RtTS group (9.1%; P=0.21).

Conclusions: RtTS TAVI is a feasible alternative access route, with comparable procedural and clinical outcomes to those of conventional approaches, albeit with a higher risk of stroke.

Background: The residential environment may influence access to care and prognosis in patients with heart failure (HF). Evidence on the impact of geographic factors in Japan is limited. We investigated the association of home‐to‐hospital distance and residential population density with 1‐year clinical outcomes in patients hospitalized for acute decompensated HF.

Methods and Results: We used the Kyoto Congestive Heart Failure registry to analyze 3,616 patients who were discharged alive after their first hospitalization. Home‐to‐hospital distance was calculated using road travel distance and dichotomized by the median (8.0 km). Residential density was classified as urban (densely inhabited districts [DID]) or suburban (non-DID). The primary outcome was all‐cause death at 1 year, assessed using hospital‐stratified Cox proportional hazards models. The median home‐to‐hospital distance was 8.0 km (interquartile range 4.1–14.5 km); 1,797 (49.7%) patients were in the long‐distance group. The long‐distance group had a higher risk of all‐cause death than the short‐distance group (adjusted hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.02, 1.39; P=0.02). As a continuous variable, each doubling of distance was associated with increased all‐cause death (HR 1.06; 95% CI 1.02, 1.10). Suburban residence was not significantly associated with the primary outcome compared with urban residence (adjusted HR 1.18; 95% CI 0.99, 1.44; P=0.06).

Conclusions: In Japanese patients hospitalized for acute decompensated HF, longer home-to-hospital distance, but not residential population density, was associated with a higher risk of 1-year all-cause death.

Background: This nationwide survey investigated new heart failure drug prescriptions by Japanese pediatric cardiologists.

Methods and Results: Among 97 responding institutions, 357 patients received sodium-glucose cotransporter-2 inhibitors (SGLT-2i; n=189), angiotensin receptor-neprilysin inhibitors (ARNI; n=89), selective hyperpolarization-activated cyclic nucleotide-gated channel (HCN) blockers (n=76), or soluble guanylate cyclase (sGC) stimulators (n=3). SGLT-2i were predominantly prescribed in post-Fontan patients (45%), with one-third being children under 18 years. ARNI were commonly used for biventricular congenital heart disease (CHD) and cardiomyopathy (47% and 29%), with 40% under 18 years.

Conclusions: Pediatric-specific clinical trials and appropriate usage guidelines are urgently needed.

Background: The impact of coexisting malnutrition and sarcopenia on survival after transcatheter aortic valve replacement (TAVR) has not been fully studied.

Methods and Results: Among 513 consecutive patients undergoing TAVR between February 2014 and June 2023, 340 with available preoperative Geriatric after Nutritional Risk Index (GNRI) and Short Physical Performance Battery (SPPB) data were categorized into 4 groups based on malnutrition (GNRI <98) and sarcopenia (SPPB ≤9) status: malnutrition and sarcopenia (N=98); malnutrition without sarcopenia (N=69); no malnutrition with sarcopenia (N=83); neither malnutrition nor sarcopenia (N=90, reference). The primary outcome measure was all-cause death. Patients with both malnutrition and sarcopenia were older and had a higher prevalence of anemia compared with the reference group. The cumulative 5-year mortality rate was significantly higher in this group. After adjusting for confounders, coexistence of malnutrition and sarcopenia had a significantly higher risk for all-cause death (hazard ratio [HR] 3.15; 95% confidence interval [CI]: 1.68–5.89; P<0.001). In contrast, malnutrition without sarcopenia (HR 1.36; 95% CI 0.64–2.90; P=0.42) and no malnutrition with sarcopenia (HR 1.86; 95% CI 0.92–3.79; P=0.08) were not associated with increased mortality.

Conclusions: The coexistence of malnutrition and sarcopenia significantly increased mortality risk after TAVR, which highlights the importance of integrating both nutritional and sarcopenia assessments into preoperative risk stratification to optimize outcomes in patients undergoing TAVR.

Background: Infective endocarditis (IE) is a life-threatening condition with high mortality. The Coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare systems, potentially affecting IE management and outcomes. However, its impact in Japan remains unclear. This study aimed to evaluate the impact of the COVID-19 pandemic on in-hospital mortality and the rate of valve surgery among patients with IE in Japan.

Methods and Results: We conducted a retrospective analysis using the Japanese registry of all Cardiac and Vascular Diseases Diagnostic Procedure Combination (JROAD-DPC) nationwide database, including 19,077 adult patients hospitalized with IE between April 2016 and March 2022. The study period was divided into pre-COVID-19 (n=12,419) and post-COVID-19 (n=6,658) periods. Patient baseline characteristics were well-balanced after 1 : 1 propensity score matching (6,652 pairs). Before matching, crude total in-hospital mortality was higher in the post-COVID-19 period (15.7% vs. 13.9%; P<0.001). However, after matching, there were no significant differences in total in-hospital mortality (15.7% vs. 15.3%, P=0.60). The rate of valve surgery did not differ significantly between the groups after matching (26.4% vs. 25.5%; P=0.22). The incidence of stroke was higher in the post-COVID-19 period (8.3% vs. 7.3%; P=0.049).

Conclusions: This nationwide study showed that risk-adjusted in-hospital mortality in patients with IE was not different during the COVID-19 pandemic, although unadjusted mortality was higher in the post-COVID-19 period in Japan.

Background: Acute coronary syndrome (ACS) is the critical situation caused by decreased blood flow of the coronary arteries. The most recent clinical guideline compiled by the Japanese Circulation Society (JCS) recommends lowering low-density lipoprotein cholesterol (LDL-C) to <70 mg/dL in patients with ACS, because of the lack of clinical evidence. It has been shown that there are substantial numbers of patients with familial hypercholesterolemia (FH) among ACS patients. On this basis, we intend assembling a multicenter registry to establish the evidence for lowering LDL-C <55 mg/dL while also clarifying the proportion of FH patients among Japanese ACS patients using a prespecified clinical pathway.

Methods and Results: The Hokuriku-plus ACS registry is a prospective, observational, multicenter cohort study, enrolling consecutive ACS patients from 14 participating hospitals in Hokuriku region of Japan from October 2025 to September 2027. A total of 1,000 patients will be enrolled followed over 1 year. The primary endpoint is the proportion of patients who attain LDL-C <55 mg/dL at 4 weeks. This study has been registered at the Japan Registry of Clinical Trials (jRCT1040250123).

Conclusions: We will disseminate the final results at international conferences and in a peer-reviewed journal.

Background: Clinical trial results suggest inclisiran lowers low-density lipoprotein-cholesterol (LDL-C), but long-term real-world data in Japanese coronary artery disease (CAD) patients are limited.

Methods and Results: We retrospectively studied 40 CAD patients treated with inclisiran and followed for 12 months, assessing LDL-C levels at baseline and every 3 months; endpoints were within-patient LDL-C change, MACE (exploratory), and safety. Mean LDL-C fell by 59%, 56%, and 57% at 3, 6, and 12 months, respectively (all P<0.05). Adverse reactions comprised 1 case of MACE and 1 of injection-site reaction over the 12 months.

Conclusions: In this single-center cohort, inclisiran was associated with sustained LDL-C reductions and acceptable tolerability over 1 year.

Background: The early detection and treatment of cancer have led to an aging population of cancer survivors, and mortality rates from cardiovascular diseases are increasing. The incidence of heart failure (HF) after treatment with paclitaxel (PTX), a microtubule polymerization promoter and cardiotoxic anticancer agent, is low and the risk factors for post-PTX HF remain unclear. A history of heart disease has been suggested as a potential cardiovascular risk factor in cancer survivors. Using the JMDC database of real-world medical data in Japan, we investigated whether heart and lifestyle-related diseases affect the onset of HF after PTX treatment.

Methods and Results: Patients who underwent PTX treatment were identified in the JMDC database, and the occurrence of HF was determined to analyze associations between heart- and lifestyle-related diseases and the occurrence of HF after PTX administration. Of the patients who received PTX, 17.7% developed HF. The results of multivariable Cox proportional hazards analysis indicated that comorbidities such as ischemic heart disease, atrial fibrillation, pericarditis, pulmonary embolism, and hypertension were associated with the onset of HF in patients receiving PTX.

Conclusions: Although the incidence of HF after PTX administration is not high, patients with specific medical histories or comorbidities may be at increased risk, and careful monitoring is warranted to detect potential cardiovascular complications.

Background: Microvascular spasm (MVS), a phenotype of microvascular dysfunction in patients with angina with non-obstructive coronary arteries (ANOCA), involves transient microvascular constriction. The angiography-derived index of microcirculatory resistance (A-IMR) is a less invasive method for assessing microcirculatory resistance. We aimed to evaluate MVS characteristics using A-IMR.

Methods and Results: We retrospectively studied ANOCA patients who underwent acetylcholine spasm provocation tests (SPT). Patients were classified into no-spasm, epicardial spasm (ECS), or MVS groups. A-IMR was measured before and after SPT. Of 109 patients, 21 (19.3%) had MVS. The MVS group had more women (76.2% vs. 42.0%; P=0.01) than the other 2 groups combined. While pre-SPT A-IMR values were similar, post-SPT A-IMR after nitroglycerin was significantly higher in the MVS group than the no-spasm group, especially in the left anterior descending (LAD) artery (44.60 vs. 33.54; P=0.007). ∆A-IMR (post- minus pre-SPT) was significantly greater in the MVS group for both the LAD (9.89 vs. −9.26; P=0.001) and right coronary artery (RCA; 3.22 vs. −6.83; P=0.001). Multivariable analysis showed ∆A-IMR in the LAD and RCA were independently associated with MVS.

Conclusions: Serial A-IMR assessment during SPT reveals sustained nitrate-resistant microvascular constriction in patients with MVS, which may confound standard post-SPT physiological assessments such as coronary flow reserve or IMR. These findings underscore the need for careful interpretation of physiological data in the presence of MVS.

Background: Dynapenia is characterized by normal muscle mass with low muscle function, but its response to cardiac rehabilitation is not fully understood, so we aimed to clarify the clinical characteristics of cardiovascular disease (CVD) patients with dynapenia and evaluate the effects of a 3month outpatient physical therapy program.

Methods and Results: Data from 62 CVD patients who completed the outpatient physical therapy program were analyzed; 12 (19.4%) met the diagnostic criteria for dynapenia. After 3 months, short Physical Performance Battery scores increased from 10.4±1.3 to 11.2±1.9, knee extension strength from 0.43±0.19 to 0.46±0.19 kgf/kg, and Mini Nutritional Assessment®︎ scores from 22.4±3.2 to 25.5±2.8 (all P<0.05).

Conclusions: Outpatient physical therapy may improve physical function, muscle strength, and nutritional status in CVD patients with dynapenia.

Background: The effectiveness of multiple arterial grafting (MAG) for hemodialysis (HD) patients is unclear.

Methods and Results: We retrospectively analyzed 149 HD patients who underwent either MAG (n=97) or single arterial grafting (SAG) (n=52). After adjusting for preoperative characteristics using inverse probability of treatment weighting, the adjusted estimated 5-year rates of freedom from all-cause death and cardiac death in the MAG vs. SAG groups were 54.8% vs. 60.4% (P=0.779) and 83.5% vs. 87.4% (P=0.869), respectively.

Conclusions: MAG did not improve the midterm outcomes for HD patients compared to SAG.

Background: There are limited numbers of studies of the relationship between maximum tongue pressure (MTP) and respiratory muscle strength in older patients with acute heart failure (AHF).

Methods and Results: Patients aged ≥65 years hospitalized with AHF were analyzed. MTP, maximal inspiratory mouth pressure (PI_max), and maximal expiratory mouth pressure (PE_max), which serve as indicators of swallowing, inspiratory, and expiratory muscle strength, respectively, were measured. The prevalence of sarcopenic dysphagia and respiratory sarcopenia was also assessed. The effect of respiratory muscle strength on MTP was evaluated using linear regression models, with MTP at the commencement of rehabilitation (baseline) or hospital discharge as the dependent variable and respiratory muscle strength measured at the baseline as the independent variable across four models. A total of 168 patients (median age: 85 years) were included in the final analysis. Sarcopenic dysphagia was observed in 16.7% of patients at baseline and 11.3% at hospital discharge (P=0.067). The prevalence of respiratory sarcopenia significantly increased from 59.7% at baseline to 70.7% at hospital discharge (P=0.018). MTP at hospital discharge was significantly associated with PI_maxat baseline (β=0.335); MTP at baseline was significantly associated with PI_maxat baseline (β=0.309).

Conclusions: PI_maxwas independently associated with MTP in older patients with AHF and may indicate a need for more intensive physical therapy interventions.

Background: The rising global older population increases the incidence of atrial fibrillation (AF), a major cause of stroke and heart failure, necessitating access to effective treatment. Catheter ablation (CA) has evolved into a primary treatment option, driven by significant advancements in device innovation, but is not available in all facilities.

Methods and Results: According to public data from Japan (the Vital Statistics survey of Japanese events in 2022, the Japanese government Survey of Household Economy, the Survey on the Impact of the Diagnosis Procedure Combination System, and publicly available data from the Japan Heart Rhythm Society), a severe regional disparity exists in access to CA due to the uneven distribution of arrhythmia specialists. Ablation procedures per 10,000 population across the 47 prefectures averaged 6.67 (95% CI: 6.19–7.12), with a range of 3.02–9.24. This access gap is the “paradox of technological innovation”, associated with inequitable treatment outcomes, higher AF-related hospitalization, and poorer quality of life in underserved prefectures. Structural threats, including a shrinking cardiologist workforce and new work constraints (Restrictions under the Work Style Reform-related Laws by the Japanese Government), risk worsening this disparity. Addressing this requires a paradigm shift toward equitable dissemination of CA.

Conclusions: The future of arrhythmia care rests not only on pursuing cutting-edge technology but also on formulating evidence-based, policy-oriented action plans to fulfill the professional and societal responsibility of eliminating treatment inequity.

Background: Acute decompensated heart failure (ADHF) causes multi-organ damage associated with congestion, hypoperfusion, or both. However, its impact on pancreatic exocrine function (PEF), which can be associated with impaired digestion and absorption and contribute to malnutrition, remains unclear. Thus, in this proof-of-concept study, we investigated whether hospitalized patients with ADHF have impaired PEF.

Methods and Results: Patients admitted to the cardiac intensive care unit were enrolled. Following initial stabilization, the N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) test, which is the only clinically available PEF test in Japan, was performed. Data from 51 patients (age 73.3±9.8 years; 80.4% men; body mass index 23.9±5.0 kg/m²) were assessed. Patients hospitalized for ADHF (n=33) exhibited significantly lower levels of urinary PABA excretion rate (i.e., pancreatic function diagnostic [PFD] value) than in those hospitalized for other cardiovascular conditions (52.4±20.1% vs. 66.4±17.3%; P=0.022). Simple regression analyses revealed that decreased PFD values were associated with advanced age, increased hemoglobin A1c level, impaired kidney function, low urinary volume in the BT-PABA test, and ADHF-related hospitalization. Multiple regression analysis revealed that only reduced estimated glomerular filtration rate (coefficient 0.319; P=0.031) and ADHF-related hospitalization (coefficient −0.326; P=0.027) were associated with poor PFD values.

Conclusions: PEF was impaired in hospitalized patients with ADHF. Our findings could inform further hypotheses regarding how improved PEF in hospitalized patients with ADHF affects their nutritional status.

Background: Primary cardiac tumors are rare, and the prognostic impact of their histological subtypes remains poorly understood. We assessed the clinical outcomes of benign and malignant tumors using long-term follow-up data from pathologically confirmed cases.

Methods and Results: We retrospectively analyzed 42 consecutive patients diagnosed with primary cardiac tumors between 2007 and 2022 at a single center. Among them, 41 patients who underwent surgical resection were followed longitudinally and included in the present study. Clinical features, tumor distribution, and outcomes were assessed by histological type, with particular focus on long-term prognosis. Histological diagnoses were confirmed in each case. Myxomas accounted for 73% (n=30), diffuse large B-cell lymphomas (DLBCLs) for 7% (n=3), and other benign tumors for 20% (n=8) of cases. Myxomas were predominantly located in the left atrium and showed excellent long-term outcomes, with no recurrence or tumor-related deaths over a median follow-up of 12.8 years. In contrast, all patients with DLBCL had right-sided tumors and died within 2 years due to disease progression despite surgery and chemotherapy. Kaplan-Meier analysis showed significant differences (P<0.001) in survival among tumor types, with DLBCL showing uniformly poor outcomes.

Conclusions: Benign cardiac tumors had favorable outcomes, with myxomas showing a particularly excellent prognosis. In contrast, malignant tumors were uniformly associated with early death. Histological subtype may be associated with survival.

Background: Caregivers of patients with heart failure (HF) provide self-care support. Caregiver Contribution to Self-Care of Heart Failure Index (CC-SCHFI) version 2 assesses the caregiver’s contribution (CC) to self-care maintenance, symptom perception, and self-care management of patients with HF. We translated CC-SCHFI version 2 into Japanese and evaluated its psychometric properties.

Methods and Results: This cross-sectional study enrolled Japanese caregivers of patients with HF. To determine structural validity, confirmatory factor analyses were conducted using the structure of the original version. Convergent validity assessed the association between each scale and self-efficacy. For internal consistency, model-based internal consistency coefficients were calculated. The participants were 103 caregivers. Regarding structural validity, the original 2-factor structure was appropriate for the CC to self-care maintenance scale. In contrast, due to model instability or low discriminant validity, 1-factor models with modifications were adopted for the CC to symptom perception and self-care management scales, showing an acceptable fit. Regarding convergent validity, all scales showed significant associations with self-efficacy. Model-based internal consistency coefficients were sufficient for all scales (0.803, 0.888, and 0.861 for the CC to self-care maintenance, symptom perception, and self-care management scales, respectively).

Conclusions: The Japanese CC-SCHFI version 2 is a reliable and valid scale for assessing the CC to self-care in Japanese patients with HF.

Background: This study aimed to examine the impact of post-discharge exercise habits on functional decline in older patients with heart failure (HF).

Methods and Results: Sixty-three older patients hospitalized due to HF (mean age 79.7±7.1 years; 46.0% male) were enrolled. Patients were categorized as exercisers if they reported engaging in moderate-intensity exercise for at least 30 min, ≥4 times per week, at 6 months post-discharge. Physical function was measured using the Short Physical Performance Battery (SPPB) at discharge and 6 months thereafter. Functional decline, the primary outcome, was defined as a decrease of ≥1 point in SPPB score over 6 months. The underlying etiologies of HF were arrhythmia (n=37; 58.7%), valvular heart disease (n=37; 58.7%), and ischemic heart disease (n=27; 42.9%). Patients were grouped into exercisers (n=36; 57.1%) and non-exercisers (n=27; 42.9%). Non-exercisers showed a significantly higher incidence of functional decline compared with exercisers (29.6% [n=8] vs. 2.8% [n=1]; P=0.003). Firth’s penalized likelihood logistic regression revealed that non-exercising status independently predicted functional decline (odds ratio 5.98; 95% confidence interval 1.41–35.44; P=0.014) after adjusting for relevant confounders.

Conclusions: Absence of post-discharge exercise habits significantly increased the risk of functional decline in older HF patients.

Background: Slow flow caused by distal embolization during percutaneous coronary intervention (PCI) worsens outcomes. Near-infrared spectroscopy with intravascular ultrasound (NIRS-IVUS) can quantify the preoperative lipid burden. We investigated the utility of combining measurement of plaque size and lipid burden.

Methods and Results: We analyzed 91 stable-angina patients undergoing NIRS-IVUS-guided PCI. Slow flow (≥1-grade TIMI decrease) occurred in 17 (18.7%). Those lesions had larger plaque area (13.8 vs. 9.9 mm², P<0.001) and higher maxLCBI_{4 mm}(625 vs. 436, P<0.001). Cutoffs were 12.0 mm²and 523, respectively. Either criterion identified all slow-flow cases (sensitivity 100%).

Conclusions: Combined assessment of plaque area and maxLCBI_{4 mm}enables simple and highly sensitive identification of lesions at risk of slow flow during PCI.

Background: Atrial fibrillation (AF) is a major risk factor for ischemic stroke, with >90% of thrombi in nonvalvular AF originating in the left atrial appendage (LAA). Thoracoscopic LAA occlusion (LAAO), with or without ablation, is a minimally invasive alternative to endocardial devices or anticoagulation, but multicenter data are limited.

Methods and Results: The Totally Thoracoscopic Left Atrial Appendage Occlusion Study (TT-LAAOS) is a multicenter Japanese registry of thoracoscopic LAAO in nonvalvular AF. From March 2018 to December 2024, 567 patients underwent the procedure at 6 institutions using stapler excision or epicardial clip. Outcomes included procedural success, anatomic closure, cerebrovascular events, and anticoagulant withdrawal. Mean age was 72 years; 63.5% had long-standing persistent AF. Median CHADS₂and CHA₂DS₂ VASc scores were 2 and 4, respectively. Success was 99.8% with no intraoperative deaths; residual stumps >10 mm were found in 1.5%. At discharge, sinus rhythm was present in 45%. Anticoagulants were stopped in 15% immediately and 63% within 1 month. During 875.8 patient years of follow-up (median 13 months), freedom from stroke or transient ischemic attack was 99.5% (0.34/100 patient years), with no thromboembolic deaths.

Conclusions: Thoracoscopic LAAO, with or without ablation, is safe and effective for stroke prevention in AF, with high success, reliable closure, and very low midterm events.

Background: Patients with myeloproliferative neoplasms (MPN) are known to complicate pulmonary hypertension (PH). Half of patients with MPN-associated PH have chronic thromboembolic PH (CTEPH); however, the prevalence, clinical characteristics, and treatment response remain unclear.

Methods and Results: Nagoya PH registry database was retrospectively analyzed. Of 129 CTEPH patients, 82 were included. Clinical characteristics and treatment response were compared between CTEPH patients with MPN (MPN group) and those without MPN (non-MPN group). As the treatment course at Nagoya University Hospital, medical treatment was initiated before performing balloon pulmonary angioplasty (BPA)/pulmonary endarterectomy (PEA). Right heart catheterization was performed at pre-medication, post-medication, and post-BPA/PEA. Seven patients had concomitant MPN as the underlying cause for CTEPH, accounting for 5.4% (7/129) of CTEPH cases. Baseline clinical characteristics were comparable between the MPN and non-MPN groups. No significant difference was observed in ∆pulmonary vascular resistance (PVR) from baseline to post-medical treatment (−3.59 WU in the MPN group vs. −3.80 WU in the non-MPN group; P=0.67) and baseline to post-BPA/PEA (−6.92 WU in the MPN group vs. −7.60 WU in the non-MPN group; P=0.35).

Conclusions: As hemodynamic responses to treatment in CTEPH patients with MPN were comparable with those without MPN, their prognosis may improve with multimodal CTEPH treatment similar to non-MPN cases.

Background: Although angiopoietin-like protein 3 (ANGPTL3) has emerged as a novel therapeutic target for lipid modulation, its prognostic significance in chronic coronary syndrome (CCS) remains unclear. This study aimed to evaluate the clinical determinants and prognostic value of circulating ANGPTL3 levels in patients with CCS.

Methods and Results: We prospectively enrolled 264 consecutive patients with CCS (median age 74 years; 73% male) undergoing cardiac catheterization. Serum ANGPTL3 levels were measured using an enzyme-linked immunosorbent assay. The primary endpoint was major adverse cardiovascular events (MACE). Female sex, elevated C-reactive protein and B-type natriuretic peptide, low high-density lipoprotein cholesterol levels, and absence of statin use were independently associated with higher ANGPTL3 levels. During follow up, 35 patients experienced MACE. In multivariable Cox regression models, ANGPTL3 remained an independent predictor of MACE. Receiver operating characteristic analysis identified 90.7 ng/mL as the optimal cut-off value for event discrimination. Kaplan-Meier curves demonstrated significantly higher event rates among patients with ANGPTL3 >90.7 ng/mL. In patients with CCS with low-density lipoprotein cholesterol (LDL-C) <70 mg/dL, elevated ANGPTL3 levels were also associated with increased MACE risk.

Conclusions: Circulating ANGPTL3 levels independently predict adverse cardiovascular outcomes in CCS, including those in patients who achieve LDL-C targets, and may help identify residual cardiovascular risk not captured by traditional lipid parameters.

Background: Although transcatheter aortic valve replacement (TAVR) improves heart failure (HF) conditions for patients with severe aortic stenosis, more than 10% of patients have HF rehospitalization within 1 year. In contrast, the continuation of loop diuretics (LD) may lead to adverse outcomes in patients with HF. This study investigated the impact of LD reduction on HF rehospitalization in post-TAVR patients using a nationwide database.

Methods and Results: This retrospective observational study used the National Database of Japan from 2014 to 2021. Patients undergoing first-time TAVR without worsening HF within 90 days post-procedure were included and categorized according to changes in LD dose at 90 days: No LD group; Reduced LD group; and Non-Reduced LD group. The primary outcome was HF rehospitalization within 2 years. Inverse probability of treatment weighting was performed to evaluate the association between LD dose changes and outcomes. Among 29,358 eligible patients, 19,070 were not prescribed LD, 5,596 were in the Reduced LD group, and 4,692 were in the Non-reduced LD group. Compared with the Non-reduced LD group, the Reduced LD group had a significantly lower risk of HF rehospitalization (HR 0.46; 95% confidence interval 0.41–0.51; P<0.001).

Conclusions: LD reduction was associated with reduced HF rehospitalization in stable HF patients after TAVR.

Cardiogenic shock (CS) caused by severe aortic stenosis (AS) is an archetype of supply-demand mismatch in which increased left ventricular afterload, impaired coronary perfusion, and concentric hypertrophy, combine to cause multiorgan hypoperfusion. Early relief of valvular obstruction through emergency transcatheter aortic valve replacement (TAVR) or, in selected cases, balloon aortic valvuloplasty (BAV) as bridge therapy, can be life-saving. Although emergency TAVR demonstrates acceptable procedural success rates and survival compared with BAV alone, short-term mortality remains high due to shock severity, comorbidities, use of mechanical circulatory support (MCS), and procedural and logistical challenges. This review outlines current hemodynamic phenotypes of CS, a streamlined door-to-valve pathway, appropriate use of MCS, a framework for selecting emergency TAVR or BAV bridging, procedural management tailored to shock physiology, and predictors of clinical outcomes, providing evidence-based guidance to optimize rescue therapy in AS patients with CS.

Background: Chronic kidney disease and cardiovascular disease (CKD-CVD) frequently coexist, creating challenges to prognosis, exercise capacity, and quality of life (QOL). CKD is common across cardiovascular conditions, underscoring the need for comprehensive management. Newer concepts of cardiovascular-kidney-metabolic syndrome (CKM) and chronic cardiovascular-kidney disorder (CCKD) emphasize shared risk factors and interconnected pathophysiological mechanisms. Within this paradigm, exercise therapy has emerged as a promising intervention to improve exercise capacity.

Methods and Results: This narrative review synthesizes conceptual advancements in the CKM-CCKD frameworks and summarizes recent literature on exercise therapy within these frameworks. The CKM-CCKD frameworks highlight the importance of addressing common risk factors and mechanisms underlying CKD-CVD. Exercise therapy comprising individualized aerobic programs is being increasingly recognized for its potential. However, its effectiveness can be limited by factors such as anemia, which correlates with impaired peak oxygen uptake and anaerobic thresholds in patients with renal dysfunction. Tailored regimens addressing reduced capacity, multimorbidity, and psychosocial factors, including patient-reported outcomes, further support inclusivity and effectiveness in clinical practice.

Conclusions: Within the CKM-CCKD frameworks, exercise therapy represents an important strategy to target shared risk factors and mechanisms in CKD-CVD. Future work should emphasize evidence-based interventions, early implementation, and individualized approaches to strengthen the translational value of these frameworks and improve QOL in this high-risk population.

Background: In order to collect information on the onset of cardiovascular disease (CVD) events for participants, the Tohoku Medical Megabank Organization (ToMMo) constructed a system to identify CVD events using a self-administered questionnaire regarding CVD onset. The association between traditional cardiovascular risk factors and CVD onset was also examined.

Methods and Results: This study included participants from the ToMMo’s Community-based Cohort Study and the Birth and Three-Generation Cohort Study. To identify CVD onset, the participants were first asked about stroke, myocardial infarction, and angina pectoris using self-administered questionnaires. Next, for those reporting onset, the ToMMo mailed structured CVD registration forms to their medical institutions. These institutions used medical records to complete and return the forms. CVD onset was then determined at event adjudication meetings involving multiple physicians and epidemiologists, based on the information from these registration forms. A nested case–control study with 602 CVD cases and 1,204 matched controls using data from a Community-based Cohort Study of the ToMMo was conducted. Using conditional logistic regression models, we found significant association between traditional CVD risk factors, such as hypertension and dyslipidemia, and CVD onset.

Conclusions: The ToMMo establishes a system for identifying CVD onset in cohort study participants. In the future, combining participants’ lifestyles and genomic information with CVD onset may help build evidence for personalized prevention and medicine.

Catheter ablation of atrial fibrillation (AF) is an established therapeutic strategy, with pulmonary vein isolation as the cornerstone of ablative therapy. Although radiofrequency and cryothermal energies have been the main energy sources, the past decade has witnessed remarkable scientific progress and growing interest in pulsed field ablation (PFA) as a novel energy modality, leading to the recent clinical adoption of PFA technologies for AF treatment. In Japan, PFA was introduced into clinical practice in 2024 and has been rapidly accepted. Unlike traditional thermal energies, PFA uses pulsed electric fields to induce irreversible electroporation, selectively targeting myocardial tissue while preserving adjacent structures from thermal or mechanical injury. Offering procedural efficacy comparable to conventional thermal ablation, PFA distinguishes itself by enabling shorter procedure times and reducing the risk of complications. This review summarizes the mechanisms of PFA, currently available systems in Japan, reported clinical outcomes and complications, as well as limitations and future perspectives.