Veno-arterial extracorporeal membrane oxygenation (ECMO) is a strong mechanical circulatory device for patients with hemodynamic deterioration due to cardiogenic shock, but its drawback is an increase in left ventricular afterload. The Impella axial-flow transcatheter left ventricular assist device is a recently developed promising device to mechanically unload the left ventricle, although its support flow may not necessarily be sufficient to support shock vital. Recently, ECMO and concomitant Impella support (ECPELLA) is increasingly being used to treat cardiogenic shock by maintaining systemic circulation and unloading the left ventricle. There are several pitfalls to maintaining ECPELLA, and one useful tool is the pulmonary artery pulsatility index. The clinical advantages of ECPELLA compared to conventional ECMO alone should be demonstrated in larger scale studies in the near future.
Evaluation of hemodynamic parameters, such as fractional flow reserve (FFR), is recommended before percutaneous coronary intervention (PCI) for patients with angina pectoris (AP). However, the advantage of FFR-guided PCI has not been fully established. This study was performed to confirm whether FFR-guided PCI improves the prognosis compared with other treatments. Multiple databases were searched for studies published from 2000 to 2018, and a network meta-analysis (NMA) was performed to compare outcomes of FFR-guided PCI, non-FFR-guided PCI, coronary artery bypass grafting (CABG), and medical treatment (MT) for AP based on estimated odds ratios (ORs). The study included 18,093 patients from 15 randomized controlled trials (RCTs). No evidence of inconsistency was observed among the studies. The NMA showed that the all-cause mortality of FFR-guided PCI was not significantly different from that of the other treatment groups (CABG: OR, 1.1; 95% confidence interval [CI], 0.67-1.7; non-FFR-guided PCI: OR, 0.85; 95% CI, 0.53-1.4; and MT: OR, 0.83; 95% CI, 0.52-1.3). The NMA for the composite of all-cause mortality and myocardial infarction, which included 15,454 patients from 12 RCTs, showed that FFR-guided PCI significantly reduced the composite outcome compared with non-FFR-guided PCI and MT (non-FFR-guided PCI: OR, 0.66; 95% CI, 0.46-0.95 and MT: OR, 0.66; 95% CI, 0.46-0.95). Although FFR-guided PCI for AP did not show significant prognostic improvement compared with non-FFR-guided PCI, CABG, and MT, FFR-guided PCI may significantly reduce the composite of all-cause mortality and myocardial infarction compared with non-FFR-guided PCI and MT.
Dickkopp-3 (DKK3) has been identified to play a protection role against atherosclerosis. However, little is known about the relationship between serum DKK3 levels and subclinical coronary atherosclerosis. We aimed to investigate the association of serum DKK3 with coronary stenosis in an asymptomatic Chinese population. A total of 550 Chinese adults aged 40-60 years and without symptoms or histories of cardiovascular diseases were randomly selected to undergo coronary computed tomography angiography. We defined ≥ 50% luminal narrowing as significant coronary stenosis and measured serum DKK3 levels by an enzyme-linked immunosorbent assay (ELISA). Fifty-nine participants had significant coronary stenosis and 223 had < 50% coronary stenosis. Proportions of significant coronary stenosis were 13.7%, 11.4%, and 7.1% in DKK3 tertiles 1-3, respectively (Ptrend = 0.0427). In the univariable multinomial logistic regression model, a decreasing DKK3 tertile was associated with significant coronary stenosis with borderline significance (OR: 1.40; 95% confidence intervals (CI): 0.98-1.99, P = 0.0642). In the multivariable regression model, participants in the lowest DKK3 tertile were associated with a 1.42-fold increased risk of significant coronary stenosis than those in the highest DKK3 tertile (OR: 2.42; 95% CI: 1.10-5.33; P = 0.0279) after adjustment for conventional cardiovascular risk factors. In addition, associations between DKK3 and significant coronary stenosis were consistent among subgroups. However, no significant association was found between serum DKK3 levels and < 50% coronary stenosis. Therefore, we have added to the existing evidence that serum DKK3 is inversely associated with the risk of significant coronary stenosis in asymptomatic middle-aged Chinese.
The prognostic capacities of nutritional status and inflammation in patients with acute myocardial infarction (AMI) have attracted increasing interest. However, the combined usefulness of the Controlling Nutritional Status (CONUT) score and neutrophil-to-lymphocyte ratio (NLR) in predicting adverse outcomes has not been investigated. The aim of our study was to investigate the relationship between the CONUT score and the NLR in patients with AMI and assessing the potential of these factors as prognostic markers.
In this retrospective study, we reviewed the medical records of consecutive patients aged 65 years or older who were diagnosed with AMI and who underwent primary coronary intervention. We assessed the nutritional and inflammatory statuses using the CONUT score and the NLR, respectively. The NLR and CONUT score in the major adverse cardiovascular event (MACE) (+) patients were significantly higher than those in the MACE (−) patients. The areas under the receiver operating characteristic curves of the NLR and CONUT score were 0.71 and 0.77, respectively. The Kaplan-Meier analysis showed that patients with a high NLR (≥6.07) and CONUT score (≥3.5) had the worst prognoses. The multivariate Cox proportional hazards analyses suggested that the CONUT score was an independent predictor.
The CONUT score was proven to be a significant prognostic factor of clinical outcomes in patients with AMI. However, further research in this area is needed to more fully understand the relationship among nutritional status, inflammation, and cardiovascular diseases, which might help reduce MACEs in patients with AMI.
Periprocedural myocardial infarction (PMI) is closely associated with long-term cardiovascular events. The factors associated with PMI are not fully understood. The purpose of this study was to investigate the determinants of PMI in contemporary elective percutaneous coronary intervention (PCI). Overall, 731 elective PCI was divided into the PMI (n = 27) and non-PMI (n = 704) groups. Univariate and multivariate logistic regression analysis was used to find factors associated with PMI. In the univariate analysis, PMI was associated with complex lesion characteristics, such as the lesion length, lesion angle, calcification, and Medina classification. In the multivariate logistic regression analysis, the lesion length (per 10-mm increase: odds ratio (OR), 1.477; 95% confidence interval (CI), 1.161‒1.879; P = 0.002), lesion angle ≥ 45° (versus lesion angle < 45°: OR, 4.244; 95% CI, 1.187‒15.171; P = 0.026), and Medina classification (0,1,1) / (1,1,1) (versus other lesions: OR, 14.843; 95% CI, 6.235‒35.334; P < 0.001) were significantly associated with PMI. Of the 24 lesions with lesion angle ≥ 45° in the PMI group, 14 had final TIMI flow grade ≤ 2 in side branches and 9 had transient slow flow in main branches/transient ST elevation during PCI. Of the 87 lesions with Medina classification (1,1,1) / (0,1,1), 19 had final TIMI grade ≤ 2 in side branches. In conclusion, the lesion length, lesion angle ≥ 45°, and Medina classification (0,1,1) / (1,1,1) were significantly associated with PMI in contemporary elective PCI. Preventing flow limitation in both side branches and main vessels in elective PCI for the diffuse long, angulated, or true bifurcation lesions is important.
Patients with impaired kidney function have a high frequency of intraplaque hemorrhage (IPH) in their coronary arteries. Levels of cyclophilin A (CyPA), an indirect matrix metalloproteinase inducer, are increased in deceased patients who had impaired kidney function. In this study, we have examined the relationship between IPH and CyPA.
We examined 47 samples of coronary plaque from 27 cadavers with coronary stenosis. These sections, all with > 50% coronary stenosis, were stained with an antibody against CyPA and the expression of CyPA was semi-quantified. Cadavers and plaques were classified into one of two groups depending on the presence or absence of IPH. IPH was defined as the presence of red blood cells stained with hematoxylin and eosin (HE) indicative of overt acute hemorrhage.
In an individual analysis, estimation of glomerular filtration rate (eGFR) in the IPH group was significantly lower than that in the non-IPH group (P = 0.002). In a histological analysis, the percentage of stained area of CyPA in the IPH group was significantly higher than that in the non-IPH group (P < 0.0001).
IPH was associated with a significantly higher expression of CyPA in this study. In addition, patients with IPH in their coronary arteries had significantly impaired kidney function.
The elevated serum levels of alkaline phosphatase (ALP) serve as independent predictors of stent thrombosis after percutaneous coronary intervention (PCI). Our study aims at investigating the relationship between the serum ALP and the responsiveness to clopidogrel. Patients undergoing elective PCI were enrolled for the study, and all participants received a 300-mg clopidogrel loading dose. The responsiveness to clopidogrel was determined by thromboelastography (TEG), and low responsiveness to clopidogrel was defined based on two aspects: (1) adenosine diphosphate (ADP) -induced platelet-fibrin clot strength (MAADP) of > 47 mm and (2) ADP-induced platelet inhibition rate of < 50%. A logistic regression model analysis was used to calculate the risks of responsiveness to clopidogrel as odd ratios (OR) and 95% confidence intervals (CIs). Overall, 809 patients were considered for the study. They were divided into four quartile groups based on the serum ALP levels. A positive linear trend was observed in MAADP across the ALP quartiles (P for linear trend < 0.001), whereas ADP-induced platelet inhibition rate decreased across the ALP quartiles (P for linear trend = 0.007). When multiple confounders were adjusted, the highest ALP quartile correlated with an increased risk of low responsiveness to clopidogrel compared to the lowest ALP quartile (OR, 1.423; 95% CI, 1.017-1.991; P = 0.039). In the sensitivity analysis, the association remained significant for different definitions of low responsiveness to clopidogrel. The elevated serum levels of ALP are independently associated with an increased risk of low responsiveness to clopidogrel.
Some patients exhibit discrepancies in carotid and coronary artery atherosclerosis. This study aimed to define the characteristics and prognosis of these discrepant patients and determine the best strategy to detect pan-vascular atherosclerosis. A database of 5,022 consecutively registered patients who underwent both coronary angiography and carotid ultrasonography, along with clinical and blood laboratory tests, echocardiography, and pulse wave velocity (PWV), was analyzed. The development of cerebro-cardiovascular (CV) events during the follow-up period was also evaluated. A significant proportion of patients (n = 1,741, 35%) presented with a discrepancy between carotid artery plaque and coronary artery disease (CAD). In patients without carotid plaque, male sex (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20-2.41; P = 0.003), older age (OR, 1.03; 95% CI, 1.01-1.04; P = 0.002), smoking history (OR, 1.58; 95% CI, 1.13-2.20; P = 0.008), lower high-density lipoprotein (HDL) -cholesterol level (OR, 0.97; 95% CI, 0.96-0.98; P < 0.001), and lower common carotid artery end-diastolic velocity (CCA-EDV) (OR, 0.97; 95% CI, 0.95-0.99; P = 0.005) were independently related to the presence of CAD. In patients without CAD, increased PWV was independently related to the presence of carotid plaque. In survival analysis, patients with isolated CAD had a higher probability of composite CV events; those with isolated carotid plaque had a higher probability of heart failure (HF) and mortality than their counterpart groups (P < 0.05). Even in patients without carotid artery plaque, careful coronary evaluation is needed in older or male patients with smoking history, lower HDL-cholesterol level, or lower CCA-EDV. Carotid plaque may be a potential risk factor for HF.
Recurrence of atrial tachyarrhythmias (ATA) following catheter ablation for atrial fibrillation (AF) is often associated with the recovery of conduction into previously isolated pulmonary veins (PVs). Little evidence concerning repeat PV isolation (PVI) and non-PV ATA ablation has been reported. This study aimed to explore the clinical outcome of recurrent ATA ablation after PVI and the difference between patients with and without non-PV ATA.
A total of 49 patients without structural heart diseases who received catheter ablation for recurrent AF between January 2014 and December 2018 were recruited (prior ablation with PVI only 71.4% and PVI with cavotricuspid isthmus line ablation 28.6%). Patients were divided into two groups according to the presence or absence of non-PV ATA.
Most patients (53.1%) experienced very late recurrence with a median duration of 15 months. A total of 15 patients had non-PV ATA and received non-PV ATA ablation whereas 34 patients received only repeat PVI for reconnected PVs. A higher pulmonary arterial systolic pressure (PASP) was associated with non-PV ATA (odds ratio: 1.161; 95% confidence interval: 1.021-1.321; P = 0.023). During 4.7 ± 1 months, 4/15 (26.7%) and 1/34 (2.9%) patients with and without non-PV ATA, respectively, had ATA recurrence (P = 0.011). The cumulative incidence of ATA recurrence after repeat ablation was significantly lower in patients without non-PV ATA (P = 0.013).
In our study, a high PASP was associated with non-PV ATA in patients with recurrent AF. Repeat PVI had a high rate of maintenance of sinus rhythm in patients without non-PV ATA.
The aim of this study was to prospectively assess the efficacy, safety, and predictive effect of intravenous nifekalant administration for persistent atrial fibrillation (PerAF) after pulmonary vein isolation (PVI) with second-generation cryoballoon ablation (CBA) on 1-year atrial tachyarrhythmia (ATa) -free survival by examining the pharmacological conversion rate.
One hundred and two drug-refractory, consecutive PerAF patients undergoing PVI were enrolled in this prospective observational study. After PVI, nifekalant (50 mg) was given followed by 30 minutes of observation and no further intervention. PerAF was successfully converted to sinus rhythm (SR) in 60 patients (58.8%) after a median time of 7.75 (4.13-12) minutes (group N). In the remaining 42 patients (41.2%) (group C), PerAF was successfully converted to SR by external electrical cardioversion. Nonsustained ventricular tachycardia occurred in 1 patient in group N. The left atrial volume (LAV) in group C was larger than that in group N (128.2 ± 28.2 versus 111.8 ± 24.5 mL, P = 0.002). Phrenic nerve injury occurred in 4 of 102 patients (3.9%). No other complications occurred during the procedure or within the 1-year follow-up period. At the 1-year follow-up, after a 3-month blanking period (BP), ATa-free survival during 1-year follow-up in group C was significantly lower than that in group N (50.0% versus 71.7%, P = 0.026), and the overall ATa-free survival rate was 62.7%. Two patients in group C and 4 patients in group N underwent a second procedure with radiofrequency catheter ablation. Multivariate Cox regression analysis demonstrated that unsuccessful conversion to SR (P = 0.025), ATa relapse during the BP (P = 0.000), and larger LAV (P = 0.016) were independent predictors of ATa recurrence at the 1-year follow-up.
In conclusion, at the 1-year follow-up, the ATa-free survival rate after PVI with CBA for PerAF patients was 62.7%, and successful conversion to SR with nifekalant could serve as a clinical predictor of reduced ATa recurrence.
Direct oral anticoagulants (DOACs) are sometimes prescribed at off-label under-doses for patients who have undergone ablation for atrial fibrillation (AF). This practice may be an attempt to balance the risk of bleeding against that of stroke or AF recurrence.
We examined outcomes of 1163 patients who continued use of a DOAC after ablation. The patients were enrolled in a large (3530 patients) multicenter registry in Japan. The study patients were classified as 749 (64.4%) appropriate standard-dose DOAC users, 216 (18.6%) off-label under-dose DOAC users, and 198 (17.0%) appropriate low-dose DOAC users.
Age and CHA2DS2-VASc scores differed significantly between DOAC dosing regimens, with patients given an appropriate standard-dose being significantly younger (63.3 ± 9.4 versus 64.8 ± 9.5 versus 73.2 ± 6.8 years, P < 0.0001) and lower (2.1 ± 1.5 versus 2.4 ± 1.6 versus 3.4 ± 1.4, P < 0.0001) than those given an off-label under-dose or an appropriate low-dose. During the median 19.0-month follow-up period, the AF recurrence rate was similar between the appropriate standard-dose and off-label under-dose groups but relatively low in the appropriate low-dose group (42.5% versus 41.2% versus 35.4%, P = 0.08). Annualized rates of thromboembolic events, major bleeding, and death from any cause were 0.47%, 0.70%, and 0.23% in the off-label under-dose group, while those rates were 0.74%, 0.73%, and 0.65% in the appropriate standard-dose, and 1.58%, 2.12%, and 1.57% in the appropriate low-dose groups.
In conclusion, the clinical adverse event rates for patients on an off-label under-dose DOAC regimen after ablation, predicated on careful patient evaluations, was not high as seen with that of patients on a standard DOAC dosing regimen.
Atrial fibrillation (AF) is the most common sustained arrhythmia. Renin-angiotensin system (RAS) inhibitors were reported to modify the arrhythmia substrate and reverse atrial remodeling. However, the role of RAS inhibitors on AF recurrence after catheter ablation remains much more controversial. In this study, a meta-analysis was performed to explore the effect of RAS inhibitors on AF recurrence after catheter ablation.
We searched PubMed, Cochrane Library, EMBASE, and Web of Science for all articles published up to July 2019 on the effect of RAS inhibitors on AF recurrence rate after ablation. We used the random-effects model to estimate the odds ratios (ORs) and confidence intervals (CI). The I2 statistic was used to evaluate statistical heterogeneity. A two-tailed P value of <0.05 was considered statistically significant. Results were further analyzed by subgroup according to the type of study design.
We included 13 studies, including 3661 patients with AF, in this analysis, of which 4 were randomized controlled trials (RCTs) and the others were cohort studies. Overall, treatment with RAS inhibitors showed a significant reduction of AF recurrence after catheter ablation (OR, 0.61; 95% CI, 0.45-0.82). Additionally, both the RCT (OR, 0.35; 95% CI, 0.24-0.49) and non-RCT (OR, 0.76; 95% CI, 0.57-1.00) groups demonstrated that RAS inhibitors could reduce the AF recurrence rate after catheter ablation in the subgroup analysis.
Our meta-analysis suggests that RAS inhibitors had significant benefit in reducing the recurrence rate of AF after catheter ablation.
The long-term prognosis for up to 20 years of patients who have undergone percutaneous transvenous mitral commissurotomy (PTMC) for mitral stenosis (MS) is unknown.
We examined 77 of 93 patients (83%) with MS and who underwent PTMC from 1989 to 2002 at our institute, as well as the occurrence of either one of the following clinical endpoints until September 1, 2018: all-cause death or repeat intervention for the mitral valve.
The mean follow-up duration was 20.5 ± 7.3 years. The mean age was 51 ± 11 years. Overall, the 20-year survival rate was 71% ± 5%; without any intervention, the 20-year survival rate was 40% ± 6%. In patients who achieved good immediate results (i.e., mitral valve area (MVA) of ≥ 1.5 cm2 without mitral regurgitation (MR) of > 2/4 after PTMC), the 20-year survival rate was 80% ± 6%; without any intervention, the 20-year survival rate was 54% ± 7%.
In our 20-year observational study, patients who have undergone PTMC for MS had favorable prognosis, especially in those who achieved good immediate results. In those who had poor immediate results, careful follow-up is needed because they might have more clinical event and any intervention for the mitral valve.
The impact of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) on changes in cardiac sympathetic nervous (CSN) function remains unclear. Using 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy, we investigated the impact of PPM after TAVR on CSN activity.
We enrolled 44 of 117 patients with severe aortic stenosis who underwent TAVR for analysis in the present study. We conducted 123I-MIBG scintigraphy at baseline and at about 9 months after TAVR. Differences between baseline and post-TAVR 123I-MIBG parameters were compared between cases with and without PPM.
There were 17 and 27 patients with and without PPM, respectively. Those without PPM exhibited significantly decreased left ventricular mass index (122 ± 36 g/m2 versus 108 ± 30 g/m2, P < 0.001) following TAVR, whereas those with PPM did not (117 ± 21 g/m2 versus 110 ± 17 g/m2, P = 0.09). Significant improvements in delayed heart-to-mediastinum (H/M) ratio (2.8 ± 0.4 versus 3.0 ± 0.4, P = 0.004) and washout rate (WR) (33% ± 10% versus 24% ± 12%, P < 0.001) were observed after TAVR in patients without PPM but not in those with PPM. Multivariable linear regression analysis revealed PPM to be a negative predictor of improvements in delayed H/M ratio and WR.
Delayed H/M ratio and WR improve significantly after TAVR in the absence of PPM, whereas these improvements are not observed in patients with PPM. Hence, the presence of PPM is a negative predictor of improvements in delayed H/M ratio and WR in patients undergoing TAVR.
Our study aimed to investigate whether the frame design of transcatheter heart valve (THV) affects the procedural and clinical results of transcatheter aortic valve implantation (TAVI).
We retrospectively reviewed 163 patients with aortic stenosis who underwent TAVI using different types of THV (Edwards SAPIEN, n = 31; Venus-A, n = 63; and J-Valve, n = 69). The procedural outcomes and follow-up results for 1-year were compared among groups.
The patients who underwent TAVI using J-Valve had a higher mean transaortic pressure gradient than those using SAPIEN or Venus-A after TAVI (1-year follow-up; P = 0.017, P < 0.001, respectively), whereas no difference was observed between the patients with SAPIEN and Venus-A prosthesis (P = 0.150). The incidence of permanent pacemaker implantation was highest in patients with Venus-A (19.0%), followed by SAPIEN (9.7%), and lowest in J-Valve (4.3%) (P = 0.025). No difference was observed in the 30-day mortality rate among the groups (P = 1.000). Moreover, Kaplan-Meier survival analysis revealed that there was no significant difference in the 1-year cumulative patient survival rate among three patient cohorts (log-rank, P = 0.850).
The frame design of THVs could affect the valve-related hemodynamics and the incidence of permanent pacemaker implantation in TAVI, whereas it did not influence the survival rate of TAVI patients during 1-year follow-up period. All three THVs provided a convincing short-term outcome for TAVI patients.
The risk of thromboembolic events is significantly increased among patients with heart failure, even in those without atrial fibrillation. However, it is still unclear whether patients with heart failure and sinus rhythm can benefit from prophylactic anticoagulant therapy.
This was a retrospective review of the pathophysiological mechanisms, epidemiological studies, and clinical trials on anticoagulation in patients with heart failure and sinus rhythm.
Some subgroup analyses of clinical trials found that prophylactic anticoagulant therapy could reduce the incidence of stroke in patients with heart failure and sinus rhythm, and the risk of bleeding was significantly increased. Regarding the incidence of primary endpoint outcomes, all results from clinical trials were negative.
Prophylactic anticoagulation did not improve the clinical outcome in patients with heart failure and sinus rhythm.
This study aims to compare and analyze the health-related quality of life (HRQoL) of adult patients with ventricular septal defects (VSDs) who underwent transthoracic or transcatheter device closure.
The HRQoL data of 30 patients who underwent transthoracic device closure for VSDs and 30 who underwent transcatheter device closure for VSDs were retrospectively evaluated before and one year after the procedure. The Medical Outcomes Study 36-Item Short-Form (SF-36), the Hospital Anxiety and Depression Scale (HADS), and a self-designed questionnaire were used as evaluation tools.
After treatment, both groups showed significant improvements in SF-36 and HADS scores. After comparing the two groups regarding the SF-36, there was a significant difference in the two dimensions of vitality and mental health. There were no statistically significant differences in the HADS-A and HADS-D scores between these two groups. The results of the self-designed questionnaire also showed that the subjective feedback of the two groups was roughly the same. In the process of exploring the influential factors, we found that the scores of patients on most dimensions of the SF-36 in the two groups showed a significantly negative trend with increasing age. In terms of HADS scores, patients in both groups showed a tendency toward increasing scores with age.
The HRQoL of adult patients undergoing transthoracic and transcatheter device closure for VSDs was similar, and the HRQoL was affected by the patient's own condition, so it is necessary to pay more attention to patients after device closure.
Transcatheter closure (TCC) has emerged as the first-line treatment for coronary artery fistulas. However, limited data exist regarding the long-term outcomes and technical aspects of this procedure. We aimed to report the long-term outcomes and technical aspects of TCC of large coronary-cameral fistulas (CCFs).
All patients with large CCFs who underwent attempted TCC using the patent ductus arteriosus (PDA) occluder or Amplatzer vascular plug (AVP), from June 2002 to December 2017, were retrospectively reviewed. A total of 23 patients with large CCFs underwent attempted TCC using the PDA occluder or AVP. Most CCFs originated from the right coronary artery and drained predominantly into the right heart chamber. Procedural success was achieved in 21 (91.3%) patients. Devices were deployed using the arteriovenous loop in 15, transarterial approach in 4, and arterio-artery loop approach in 2 patients. Procedural complications included coronary spasm in one and side branch occlusion in one patient. Among these 21 patients with successful device implantation, follow-up angiograms or computed tomography angiograms were obtained in 14 (66.7%) patients at a median of 11.0 (range, 9.8-16.3) months. Late complications included thrombosis of residual fistula segment without myocardial infarction (MI) in one, coronary thrombosis resulting in MI in one, and recanalization necessitating re-intervention in one patient. No death and device embolization occurred.
TCC of large CCFs using the PDA occluder or AVP is an effective therapy in anatomically suitable candidates, with favorable long-term outcomes. Given that potentially hazardous complications may occur late after the procedure, long-term periodic evaluation is mandatory.
Various surgical techniques have been proposed for treating aortic arch aneurysm (AAA); however, the optimal treatment has not been well defined. This study introduces a new aortic arch inclusion technique with frozen elephant trunk (FET) for AAA treatment.
A retrospective analysis was performed among 22 patients for AAA surgical treatment between March 2010 and March 2019. Patients were classified into Z1, Z2, and Z3 groups based on the origins of aneurysms. A stent graft with a 10 cm stented graft and 5-9 cm proximal vascular prosthesis was released into the descending thoracic aorta as FET through an incision in the aortic arch. The proximal vascular prosthesis was retracted into the aortic arch, trimmed to expose the orifices of the brachiocephalic vessels, and sutured inside the aortic arch using the inclusion technique. The proximal sealing location of the vascular graft was tailored to cover the origins of aneurysms.
There was no 30-day mortality. No patient had postoperative stroke or paraplegia. Complete aneurysm thrombosis was achieved in all patients. One patient died of severe respiratory tract stenosis 3 months postoperatively. All other 21 patients were alive during 53.3 ± 36.5-month follow-up. Computed tomography angiography was obtained in 15 patients during follow-up. Endoleak was observed in one patient, and the other 14 patients were free from aneurysm-related or graft-related complications during follow-up.
The aortic arch inclusion technique with FET provides an alternative technique in treating AAA with satisfactory mid-term follow-up results. A larger patient population with long-term follow-up results is warranted.
After the new left ventricular ejection fraction (LVEF) classification criteria emerged, many studies have focused on the differences between heart failure (HF) with reduced EF (HFrEF), HF with midrange EF (HFmrEF), and HF with preserved EF (HFpEF). However, the lack of consensus on sex-related differences in prognosis within the new standard remains. We aimed to explore sex differences in the clinical characteristics and prognoses of Chinese inpatients with HF defined according to the new standard.
From March 2014 to February 2016, 2284 patients with symptomatic HF were consecutively recruited to this prospective research. Case data and 2-year follow-up observations were used to identify sex differences in clinical characteristics and prognoses.
When comparing men and women with HFrEF, HFmrEF, and HFpEF, women were older, were more likely to be hospitalized for the first diagnosis of HF, and had lower mean LVEF. Women had a higher tendency of all-cause mortality than did men at 3, 12, and 24 months following HF. After multivariate adjustment, the hazard ratios (HRs) for 24-month all-cause mortality for HFrEF, HFmrEF, and HFpEF were 1.113 (0.728, 1.704), P = 0.620; 1.063 (0.730, 1.548), P = 0.750; and 0.619 (0.240, 1.593), P = 0.320, for men versus women, respectively.
There were some sex differences in the clinical characteristics of patients with symptomatic HF in HFrEF, HFmrEF, and HFpEF, but women and men had comparable outcomes over the 2-year period following hospitalization.
Home treatment for heart failure (HF) is one of the most important problems in patients after discharge as a secondary preventive measure for rehospitalization for HF. However, there are no detailed studies on gender differences in sociopsychological factors such as living alone for HF rehospitalization among patients with acute HF (AHF).
This prospective multicenter cohort study enrolled patients with AHF between April 2015 and August 2017. Patients of each gender with first AHF were divided into those living alone and those not living alone. The primary endpoint was defined as rehospitalization for HF after discharge. Cox proportional hazard analysis was performed to determine the association between living alone and the endpoint.
Overall, 581 patients were included in this study during the 3-year follow-up. The proportion of rehospitalization for HF was significantly higher in patients living alone than in those not living alone among male patients. However, female patients showed no difference in endpoints between the two groups. The difference was independently maintained even after adjusting for differences in social backgrounds in male patients (adjusted hazard ratio (HR) 2.02; 95% confidence interval (CI), 1.07-3.70). In female patients, the HR for rehospitalization for HF showed no difference between the two groups (adjusted HR, 0.99; 95% CI, 0.56-1.69).
In this study population, male patients living alone after first AHF discharge had a higher risk of rehospitalization for HF than those not living alone, but these differences were not observed in female patients.
Heart failure (HF) is a major cause of death and hospitalization worldwide. In particular, hospital readmission due to worsened HF occurs frequently after the onset of HF. However, the association of repeated hospital admission with clinical manifestations and outcomes is unclear. The aim of this study was to clarify the serial changes in presentation and clinical course of patients requiring repeated hospital admission due to worsened HF. Among 466,921 patients who were admitted and discharged between January 2010 and March 2018, with the main discharge diagnosis of HF, we studied 5,740 patients who were hospitalized 4 times or more, using the Diagnosis Procedure Combination database. We evaluated serial changes in continuous data using the Jonckheere trend test, and categorical data using the Cochran-Armitage trend test. The median age of the patients was 78 years, and 3,326 patients (58%) were male. Body mass index and Barthel Index decreased with increased numbers of admissions. Patients requiring respiratory support and hemodialysis increased, whereas patients undergoing intra-aortic balloon pumping decreased with increased numbers of admissions. The length of hospital stay was prolonged and the interval between hospitalizations was shortened with increased numbers of hospital admissions. The in-hospital mortality rate was 8.8% at the fourth admission. In conclusion, this is the first large-scale real-world study on the serial changes in characteristics and outcomes of HF patients requiring repeated hospitalization, suggesting that repeated hospitalization might adversely affect the general status of patients with HF and result in a vicious clinical cycle.
We aimed at exploring the function of microRNA-324/cytokine signaling 3 (miR-324/SOCS3) axis in hypoxia/reoxygenation (H/R) -induced cardiomyocyte injury and its underlying mechanism. The differential expression genes were analyzed based on the GSE83500 and GSE48060 datasets from the Gene Expression Omnibus (GEO) database. Then, to conduct the function enrichment analysis, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) databases were used. The upstream regulatory microRNAs (miRNAs) of the identified genes were predicted by miRanda, miRWalk, and TargetScan websites. MiR-324 expression was measured with quantitative real-time polymerase chain reaction (qRT-PCR). The target binding of miR-324 and SOCS3 was established by dual-luciferase reporter assay. Cardiomyocyte proliferation was analyzed by cell counting kit-8 (CCK-8) assay, whereas the apoptosis was investigated via flow cytometry. The expression of TNF pathway-related proteins was detected by western blot analysis. SOCS3 was upregulated in patients with myocardial infarction (MI), and function enrichment analyses proved that SOCS3 was enriched in TNF signaling pathway. Moreover, we found that miR-324 was the upstream regulatory miRNA of SOCS3 and negatively regulated SOCS3 expression. MiR-324 was downregulated in cardiomyocytes with H/R-induced injury, inhibiting cell proliferation. In the H/R model, SOCS3 suppresses cardiomyocyte proliferation, which was recovered by miR-324, and induces cell apoptosis, which was repressed by miR-324 via regulating the expression of cleaved caspase-3 and p P38-MAPK. MiR-324 upregulation decreased the protein levels of TNF-α, p-P65, and p-IκBα in cardiomyocytes that suffered from H/R, which was reversed with SOCS3 overexpression. MiR-324/SOCS3 axis could improve the H/R-induced injury of cardiomyocytes via regulating TNF/NF-κB signaling pathway, and this might provide a new therapy strategy for myocardial ischemia.
Atrial fibrillation (AF), one of the common clinical arrhythmias, lacks effective treatment manners. Cardiac fibroblasts play an essential role in myocardial fibrosis and cardiac remodeling, which are involved in AF progression. Reportedly, MicroRNAs (miRNAs) regulate the myocardial fibrosis in AF. However, whether miR-324-3p involves myocardial fibrosis in AF and the tentative molecular mechanisms of miR-324-3p regulating cardiac fibroblasts during AF remains unknown. In the present study, miR-324-3p was found to be decreased in patients with AF and AF rat model. Next, we investigated the effect of miR-324-3p on myocardial fibroblast proliferation through miR-324-3p overexpression and found that miR-324-3p inhibited fibroblast proliferation in vitro. Furthermore, we found that miR-324-3p directly targeted transforming growth factor β1 in fibroblast, which may be involved in the development of myocardial fibrosis during AF. Meanwhile, miR-324-3p mimics treatment suppressed the PI3K/AKT signaling pathway in fibroblast. These results demonstrated a molecular mechanism of miR-324-3p regulating fibroblast proliferation in vitro, which might provide a novel potential treatment manner in AF in clinic.
Duchenne muscular dystrophy (DMD) is X-linked recessive myopathy caused by mutations in the dystrophin gene. Although conventional treatments have improved their prognosis, inevitable progressive cardiomyopathy is still the leading cause of death in patients with DMD. To explore novel therapeutic options, a suitable animal model with heart involvement has been warranted.
We have generated a rat model with an out-of-frame mutation in the dystrophin gene using CRISPR/Cas9 genome editing (DMD rats). The aim of this study was to evaluate their cardiac functions and pathologies to provide baseline data for future experiments developing treatment options for DMD.
In comparison with age-matched wild rats, 6-month-old DMD rats showed no significant differences by echocardiographic evaluations. However, 10-month-old DMD rats showed significant deterioration in left ventricular (LV) fractional shortening (P = 0.024), and in tissue Doppler peak systolic velocity (Sa) at the LV lateral wall (P = 0.041) as well as at the right ventricular (RV) free-wall (P = 0.004). These functional findings were consistent with the fibrotic distributions by histological analysis.
Although the cardiac phenotype was milder than anticipated, DMD rats showed similar distributions and progression of heart involvement to those of patients with DMD. This animal may be a useful model with which to develop effective drugs and to understand the underlying mechanisms of progressive heart failure in patients with DMD.
The risk factors of carotid stenosis and coronary stenosis are similar, and therefore, certain patients with carotid stenosis may have coronary heart disease. Coronary artery bypass graft (CABG) is the major therapy for ischemic heart disease with three-vessel and left main coronary artery (LMCA) disease. However, CABG can induce cerebral infarctions in cases with carotid stenosis. Carotid endarterectomy (CEA) was used to be the standard therapy for carotid stenosis; however, CEA requires general anesthesia and has a high risk of cardiovascular events in patients with ischemic heart disease. In recent times, carotid artery stenting (CAS), which does not need general anesthesia, is the new strategy for carotid stenosis. However, CAS induces hypotension and bradycardia because of a carotid node reflex, which is dangerous in patients with ischemic heart disease. We reported a case of the coexistence of severe coronary stenosis including the LMCA and three vessels and carotid stenosis. CAS before CABG under local anesthesia was successful with the use of intra-aortic balloon pumping (IABP) and a temporary pacemaker.
Essential thrombocythemia (ET) is a Philadelphia chromosome-negative myeloproliferative disorder that is characterized by the overproduction of platelets and a marked increase in the numbers of mature megakaryocytes present in the bone marrow. Thrombohemorrhagic disorders are major morbidities of ET, especially those with mutations in the gene encoding Janus kinase 2 (JAK2). In this study, we report the case of an 18-year-old patient with ET carrying JAK2 mutation who developed acute ST-elevation myocardial infarction (STEMI) 5 months after a commencement of anagrelide. Coronary endothelial dysfunction confirmed by positive acetylcholine provocation test lasted a year after the occurrence of STEMI. Furthermore, intracoronary imaging using optical coherence tomography demonstrated non-atheromatous intimal fibrosis possibly due to chronic endothelial damage. The coronary pathologies reflected chronic change potentially associated with properties of ET and JAK2 mutation in addition to hyperviscosity. These observations suggest that the side effect of anagrelide in our patient was considered causative, while underlying chronic endothelial dysfunction and adverse endothelial remodeling may be predisposing factors to his fatal cardiovascular events.
Porcelain aorta, defined as extensive calcification of the ascending aorta or aortic arch, is a reported risk factor for embolic stroke during cardiac surgery. However, the time course of the progression of aortic calcification leading to porcelain aorta has not been elucidated. We herein describe a 70-year-old woman who was followed up for systemic lupus erythematosus and antiphospholipid syndrome for approximately 20 years. A routine computed tomography scan revealed progression of ascending aortic calcification to porcelain aorta. The calcification was absent during the preceding 12 years, partial 6 years later, and total after another 3 years. Computed tomography also demonstrated aortic and mitral valve calcification in the development of porcelain aorta. During the 3 years prior to the last admission, annual echocardiography examinations showed progression of calcific aortic stenosis with symptoms. The patient was admitted to our institution for aortic valve replacement. Considering the high risk of perioperative stroke associated with porcelain aorta, transcatheter aortic valve implantation was performed. Postoperative transthoracic echocardiography revealed improvement of the aortic stenosis with no symptoms. The present case revealed aortic calcific progression to porcelain aorta during an approximately 10-year period with deterioration of aortic stenosis within a short time. The aortic and valvular calcification could be attributed to the inflammatory process of systemic lupus erythematosus and antiphospholipid syndrome. The presence of aortic and mitral annular calcification in the serial imaging can provide information on aortic and valvular atherosclerotic progression, which may be modifiable by early steroid-lowering therapy.
Takotsubo cardiomyopathy (TTC) is characterized by reversible ventricular dysfunction induced by endogenous and, occasionally, exogenous catecholamine. We present a report on a patient who developed TTC and cardiogenic shock during percutaneous coronary intervention (PCI) secondary to inadvertent norepinephrine administration. His hemodynamic status and cardiac function were totally restored within 1 week after hemodynamic support using intra-aortic balloon pump without sequela. Thus, TTC should be considered once a patient presents with symptoms mimicking acute coronary syndrome (ACS) after catecholamine administration.
The patient was a 59-year-old female with advanced heart failure and severe functional mitral regurgitation who was classified as INTERMACS profile 4 with repeated hospitalizations despite guideline-directed medical therapy. She was also listed for heart transplantation. After comparing the two major therapeutic strategies: (1) durable left ventricular assist device (LVAD) implantation and (2) percutaneous MitraClip procedure (Abbott Vascular, Abbott Park, IL, USA), we eventually decided to proceed with MitraClip, given her relatively lower B-type natriuretic peptide, lower MAGGIC Heart Failure risk score, and higher predicted survival without LVAD. The post-procedural course was favorable without any comorbidities or worsening of heart failure for 10 months. A diagnostic paradigm to guide which strategy to choose (LVAD or MitraClip) for patients with advanced heart failure and functional mitral regurgitation should be constructed.
Acute pericarditis is inflammation of the pericardium with or without pericardial effusion. In the pediatric population, most patients with acute pericarditis are diagnosed with idiopathic pericarditis. Herein, we present two children with idiopathic pericarditis who underwent immunological assessment of pericardial effusion for the first time. Both patients showed equally high levels of interleukin-6 in the pericardial effusion. However, they had different treatment responses, in accordance with the pericardial effusion and serum interleukin-10 concentrations. Our present cases suggest that interleukin-10 may be associated with the response to anti-inflammatory therapy in idiopathic acute pericarditis.
Although some researches proved the influence of radiation therapy (RT) on pacemakers and implantable cardioverter defibrillators, little has been reported on cardiac resynchronization therapy defibrillators (CRTDs). We experienced a case of RT on CRTD and had a new finding.
A patient with CRTD implanted for dilated cardiomyopathy was diagnosed with lung squamous cell carcinoma and started receiving RT. All the implanted devices, including the main body of CRTD, left ventricular lead (LV), right ventricular lead with high-voltage conductor, and right atrial lead, were from the same manufacturer. The radiation targeted the tumor of 67 mm in diameter in the right superior lobe for 5 min per session. The CRTD was outside the radiation field, which is 65 mm, but the leads were inside. Plan 1 used 2 Gy/fr with 8 megavolt photons, and Plan 1 was irradiated at 0° and 180° for 16 RT sessions. The dosage was increased to 3 Gy for Plan 2 for 4 sessions. Plan 3 used 2 Gy with 6 and 8 megavolt photons, and Plan 3 was irradiated at 27.7° and 200.7° for 11 RT sessions. Changes in measured parameters were assessed before and after RT.
Changes in impedance of LV and high-voltage lead exceeded prespecified threshold. However, no significant errors were detected in the CRTD on the dosages and energy we used.
We hypothesize that the lead insulator could have been affected by radiation.