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: 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.

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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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.

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.