The bending technique of a scoring balloon Aperta NSE leading to successful crossing into stents.

A new scoring balloon Aperta NSE has 3 longitudinal nylon elements mounted on the non-compliant balloon surface. Although a high-pressure balloon is usually used as a post-dilation balloon in an implanted stent, it is difficult to pass into the stents because a balloon gets caught in stents in some cases. Aperta NSE has some grooves at elements; therefore, this balloon is bendable and shaped in an arc. The bent scoring balloon could eliminate interference between the balloon and the stents or lesions. Moreover, the point where the tip of the balloon contacts could change. As a result, it helps to improve crossability of this balloon. The bending technique of a scoring balloon Aperta NSE could lead to successful crossing into stents or complex lesions.

Efficacy and Safety of Sitafloxacin in Treating Low-risk Febrile Neutropenia in Patients with Lung Cancer.

Introduction: Febrile episodes in patients with cancer and chemotherapy-induced neutropenia can be life-threatening and generally require prompt administration of broad-spectrum antimicrobials. However, little evidence exists for treating patients with solid tumors and febrile neutropenia (FN) with oral antimicrobials. Methods: In this prospective study, we aimed to determine the efficacy and safety of sitafloxacin (STFX) for treating FN in lung cancer patients. In this prospective study, low-risk FN patients with lung cancer received STFX. The primary endpoint was response rate, defined as 5 sequential days of absence of fever without adverse events. The study was registered as UMIN000010911. Results: As a result, STFX was administered to 26 patients, all of whom survived during its administration. Of the 26, 14 completed primary endpoint (53.85%). The low response rate was attributed to occurrence of fevers of unknown cause rather than failure of FN treatment. Only two patients received antibacterial agents other than STFX. If response rate omitted absence of fever and been defined only as recovery from FN without changing microbial agents or serious complications, the response rate would have been 91.67%. Adverse events occurred in eight patients, none of which were serious. Conclusions: In conclusion, STFX might be used to treat low-risk FN in patients with lung cancer; however, a more detailed study will be required in future.

Transcatheter aortic valve implantation with a balloon-expandable prosthesis in a patient with single coronary artery: a case report.

Background: Single coronary artery is a rare coronary artery anomaly with an incidence of <0.03%. The coexistence of coronary artery anomalies with severe aortic stenosis is extremely rare. Due to the singularity of the coronary artery orifice, the most concerning risk of transcatheter aortic valve implantation (TAVI) in such patients is coronary occlusion, which may very well be life-threatening. Case summary: An 83-year-old female complaining of chest pain was referred to our hospital for severe aortic stenosis. The multi-slice computed tomography showed a congenital single coronary artery originating from the right sinus of Valsalva. The left coronary artery branched off of the right coronary artery, and passed between the aorta and main pulmonary artery. The heart team of the hospital decided to perform TAVI via femoral artery with a balloon-expandable prosthesis, with coronary angioplasty devices on standby in case of coronary occlusion. The TAVI procedure was performed successfully without coronary occlusion. Discussion: Although there have been some case reports of TAVI in patients with single coronary artery, little is known about the safety of TAVI in such cases, and which device (such as the balloon-expandable or the self-expandable prosthesis) is preferable. From this particular case, and accumulation of past and various TAVI experience, the balloon-expandable prosthesis can be a safe device choice in carefully selected patients with coronary artery anomalies.

Left atrial appendage orifice dimensions in Japanese atrial fibrillation population measured by multiplane transesophageal echocardiography.

BACKGROUND: Successful implantation of the WATCHMAN device requires an accurate understanding of left atrial appendage (LAA) anatomy and orifice dimensions. Racial differences are observed in LAA size when comparing Asians with non-Asians. METHODS: A total of 170 patients (123 male, 67.4 ± 9.2 years) with paroxysmal or persistent atrial fibrillation (AF) underwent transesophageal echocardiography before catheter ablation or cardioversion (September 2018 to September 2019). As per the recommendations of the WATCHMAN device, the maximal LAA ostial diameters were measured at multiplane angles of 0°, 45°, 90°, and 135°. RESULTS: The majority of patients (121/170, 71%) had an LAA orifice size within 17-25 mm. Fifteen (8.8%) patients had undersized (< 17 mm) and eight (0.5%) had oversized (> 31 mm) LAA. One patient in this population had no LAA. LAA size was significantly larger in patients with persistent AF than in those with paroxysmal AF (23.3 ± 4.2 mm vs. 20.0 ± 3.0 mm, p < 0.001) and in male patients than in female patients (22.4 ± 4.2 vs. 20.9 ± 3.7 mm, p = 0.03). LAA orifice dimension was significantly correlated with CHADS2 score, the left atrial volume (LAV), E/e', and the left ventricular ejection fraction. Persistent AF, body mass index, and LAV were independently associated with LAA orifice dimension in multivariate analysis. CONCLUSION: This study demonstrated the distribution of LAA orifice dimension in the Japanese AF patients. This finding should be used as a reference to understand the racial characteristics of LAA size for the WATCHMAN procedure.

Impact of osteogenic activity on degenerative aortic valve disease in patients with osteoporotic hip fracture.

BACKGROUND: Previous studies have proposed that osteogenic and apoptotic processes of valve interstitial cells contribute to the mineralization and then calcification of the aortic valve. Osteoblast-like cells subsequently mediate calcification of the aortic valve as part of a highly regulated process analogous to skeletal bone formation. The objective of this study was to evaluate the pathogenesis of the sclerotic/calcific changes in the aortic valve from histological and biological findings, and investigate the role of osteoblasts in the calcified pathway of aortic stenosis. METHODS: Preoperative echocardiography in 550 consecutive patients with osteoporotic hip fracture were retrospectively examined (475 females, mean 25th-75th, 89 [85-93] years). One hundred sixteen patients were under medical treatment with anti-osteoporosis drugs. We evaluated the prevalence and degree of degenerative changes in the aortic valve and examined the associations of bone turnover biomarkers N-terminal pro-peptide of type 1 collagen (P1NP) and serum tartrate-resistant acid phosphatase (TRACP-5b) with degenerative calcific changes in the aortic valve. RESULTS: Of 550 patients, 112 patients (20.9%) showed no leaflet calcification; 296 (53.8%), 1 leaflet calcification; and 142 (25.8%), 2 ≥ leaflets calcification. Significant (peak velocity ≥ 3.0m/s) Aortic stenosis was found in 43 patients (7.8%). In patients who were not taking anti-osteoporotic drugs, P1NP was higher in the 2 ≥ leaflets calcification group than in the other groups (p < 0.01). TRACP-5b was not significantly different among the three groups (p = 0.15). CONCLUSIONS: Degenerative changes in the aortic valve were related to bone biomarker activation in osteoporotic hip fracture patients.

A long-term survivor keeping in a complete response without treatment after pemetrexed maintenance therapy for advanced non-squamous non-small cell lung cancer.

Pemetrexed has significant efficacy for some non-squamous non-small cell lung cancer cases, as demonstrated in the current case. For those patients, pemetrexed administration should be carefully considered.

Impact of frailty on outcomes in elderly patients with acute myocardial infarction who undergo percutaneous coronary intervention.

AIMS: Frailty is characterized by reduced biological reserves and weakened resistance to stressors, and is common in older adults. This study evaluated the prognostic implications of frailty at hospitalization in elderly patients with acute myocardial infarction (AMI) who undergo percutaneous coronary intervention (PCI). METHODS AND RESULTS: We prospectively analysed 546 AMI patients aged ≥80 years undergoing PCI from 2009 to 2017. Frailty was classified based on impairment in walking (unassisted, assisted, and wheelchair/non-ambulatory), cognition (normal, mildly impaired, moderately to severely impaired), and basic activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and patients were categorized into the following three groups based on total score: no frailty (0), mild frailty (1-2), moderate-to-severe frailty (≥3). The median follow-up period was 589 days. Of the 546 patients, 27.8% were frail (mild or moderate-to-severe), and this proportion significantly increased to 35.5% at discharge (P < 0.001). Compared to non-frail patients, frail patients were older, less likely to be male, and had a higher rate of advanced Killip class. Major bleeding (no frailty, 9.6%; mild frailty, 16.9%; moderate-to-severe frailty, 31.8%; P < 0.001) and in-hospital mortality (no frailty, 8.4%; mild frailty, 15.4%; moderate-to-severe frailty, 27.3%; P < 0.001) increased as frailty worsened. After adjusting for confounders, frailty was independently associated with higher mid-term all-cause mortality (hazard ratio, 1.81; 95% confidence interval, 1.23-2.65; P = 0.002). CONCLUSION: Frailty in AMI patients aged ≥80 years undergoing PCI was associated with major bleeding, in-hospital death, and mid-term mortality.

Hypertrophic pulmonary osteoarthropathy due to lung cancer: A case report and literature review.

Hypertrophic pulmonary osteoarthropathy (HPOA) is a rare paraneoplastic syndrome. Our literature review shows the location of arthralgia and existence of edema are referable information for the differential diagnosis in paraneoplastic arthralgia.

Unique mechanism of mitral valve prolapse in atrial septal defect: Three-dimensional insights into mitral complex geometry using real-time transesophageal echocardiography.

BACKGROUND: Mitral valve prolapse (MVP) is often identified in patients with atrial septal defect (ASD), which occasionally require surgical intervention at the time of ASD closure or even long after the surgery. Ventricular and valvular geometric characteristics in preoperative ASD patients were evaluated by three-dimensional (3D) transesophageal echocardiography. METHODS AND RESULTS: Mitral valve (MV) complex geometry was quantitatively measured by 3D transesophageal echocardiography in 11 ASD patients (Qp/Qs > 1.5) and 11 controls. The ASD group had a significantly larger indexed prolapse volume and height, with a larger anterior mitral leaflet than controls (0.53 [0.33-0.75] vs 0.057 [0.027-0.11] mL/m2 , P = .0001; 2.89 [2.13-3.50] vs 0.92 [0.48-1.32] mm/m2 , P < .0001; 391.3 [346.4-445.1] vs 295.3 (281.9-330.0) mm2 /m2 , P = .011, respectively). The right ventricular (RV)-to-left ventricular (LV) end-systolic diameter ratio was larger in the ASD group than in the control group (1.34 [0.96-1.45] vs 0.85 [0.75-0.88], P = .004). The indexed inter-papillary muscle distance (IPMD) was significantly shorter in the ASD group than in the control group (7.77 [6.55-8.24] vs 9.71 [8.64-10.8] mm/m2 , P = .011). IPMD was significantly correlated with the RV-LV end-systolic diameter ratio (r = -.70, P = .017). CONCLUSIONS: Inward shift of the LV papillary muscle tips due to RV dilation may be a major mechanism of MV prolapse in ASD. At the same time, positive remodeling of the anterior leaflet was observed in the ASD group, which may compensate for the billowing leaflet geometry to maintain effective coaptation. Three-dimensional assessment of the MV apparatus geometry will help to further understand perioperative mitral regurgitation in patients with ASD.

Radiation-induced sarcoma in a 10-year survivor with stage IV EGFR-mutated lung adenocarcinoma.

A 70-year-old Japanese man with stage IV EGFR-mutated lung adenocarcinoma complained of right mild back pain. The patient had been heavily treated with several cytotoxic or molecular targeted agents for 10 years and received a palliative radiation therapy of 2nd sacral vertebra 5 years ago. Computed tomography showed the abnormal lesion in right iliopsoas muscle. A pathological examination confirmed undifferentiated pleomorphic sarcoma, consistent with the diagnosis of radiation-induced sarcoma (RIS). Since RIS is a rare late-onset complication of radiation therapy, to our knowledge, this is the first report of RIS that was associated with advanced lung cancer and detected after palliative radiation therapy. The careful long-term follow-up is thus necessary even after palliative radiation therapy and we have to be aware of the existence of RIS.

Do infections with disseminated Mycobacterium avium complex precede sweet's syndrome? A case report and literature review.

Sweet's syndrome is reportedly associated with preceding nontuberculous mycobacterial infections (NTMIs). Here, we report on a systemic Mycobacterium intracellulare infection in a patient on corticoid therapy for Sweet's syndrome. Literature searches show that 69.1% of patients with Sweet's syndrome and NTMIs developed this syndrome later than NTMIs and 89.3% of them developed during the clinical course of a rapidly growing mycobacterial infection. The residual cases were associated with slow-growing mycobacteria (14.3%), but only three cases of Mycobacterium avium complex (MAC) infections before the onset of Sweet's syndrome have been reported, and all of them were caused by disseminated MAC disease. One of these cases developed during corticoid therapy for Sweet's syndrome, while another case had underlying diabetes mellitus. Hence, the occurrence of systemic MAC disease may be an inevitable consequence of long-term steroid use and underlying diseases. Literature searches also show that cervical lymphadenitis was a predominant symptom in NTMIs (90.5%). The present case did not have cervical lymphadenitis although the previously reported MAC cases did experience it. Therefore, lymphadenitis from NTMIs may be related to the pathogenesis of Sweet's syndrome. Hence, should a patient have systemic infection without lymphadenitis, it will be more difficult to clinically confirm that MAC disease is a predisposing factor for Sweet's syndrome.

Predictors of Recurrent In-Stent Restenosis After Paclitaxel-Coated Balloon Angioplasty.

BACKGROUND: Although paclitaxel-coated balloon (PCB) angioplasty is an effective procedure for in-stent restenosis (ISR) after coronary stenting, recurrent ISR after PCB angioplasty still occurs. The aim of this study was to evaluate the predictors of recurrent ISR after PCB angioplasty for ISR.Methods and Results:A total of 157 ISR lesions treated with PCB angioplasty from January 2014 to May 2015 were retrospectively examined. Recurrent ISR was judged on 6-month follow-up angiography. Clinical, angiographic and procedural parameters were evaluated as possible predictors of recurrent ISR. Recurrent ISR occurred in 13.9% of lesions after PCB angioplasty. On multivariate analysis the following independent predictors of recurrent ISR were identified: (1) smaller acute gain after initial ballooning (OR, 3.06; 95% CI: 1.08-8.71; P=0.04); (2) geographic mismatch between PCB position and initial ballooning (OR, 5.59; 95% CI: 1.64-19.1; P=0.006); and (3) use of percutaneous transluminal coronary rotational atherectomy (PTCRA) at primary percutaneous coronary intervention (PCI; OR, 5.53; 95% CI: 1.89-16.2; P=0.002). CONCLUSIONS: Optimal expansion at initial ballooning before PCB angioplasty and careful positioning of PCB are important technical tips to prevent recurrent ISR after PCB angioplasty. Recurrent ISR occurred more frequently in severely calcified lesions that required PTCRA at primary PCI.

The Course of Ischemic Mitral Regurgitation in Acute Myocardial Infarction After Primary Percutaneous Coronary Intervention: From Emergency Room to Long-Term Follow-Up.

BACKGROUND: Previously published evidence on ischemic mitral regurgitation (IMR) and its adverse prognosis after myocardial infarction has been based on the severity of IMR in the subacute or chronic period of myocardial infarction. However, the state of IMR can vary from the early stage to the chronic stage as a result of various responses of myocardium after primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: Standard echocardiography was serially performed in 546 consecutive patients with first-onset acute myocardial infarction (1) immediately after their arrival (pre-PCI), (2) before discharge (early post-PCI), and (3) 6 to 8 months after PCI (late post-PCI). The course of IMR after primary PCI and the prognostic impact of the IMR in each phase were investigated. IMR was found in 193/546 (35%) patients at the emergency room. In the acute phase after PCI, IMR improved in 63 patients. IMR worsened in 78 patients despite successful PCI. Shorter onset-to-reperfusion time and nontotal occlusion before PCI were the independent predictors of early improvement of IMR. In the chronic phase, IMR improved in 79 patients and worsened in 36 patients. Lower peak creatine kinase-myocardial band was an independent predictor of late improvement of IMR. IMR before PCI worsened 30-day prognosis (P=0.02), and persistent IMR in the chronic phase worsened long-term prognosis (P=0.04) after primary PCI. CONCLUSIONS: Degrees of IMR changed in the early and chronic phase after primary PCI for acute myocardial infarction. IMR on arrival and persistent IMR in the chronic phase worsened short-term and long-term prognosis after acute myocardial infarction, respectively.

Clinical Implications of Additional Pedal Artery Angioplasty in Critical Limb Ischemia Patients With Infrapopliteal and Pedal Artery Disease.

PURPOSE: To evaluate the clinical implications of additional pedal artery angioplasty (PAA) for patients with critical limb ischemia (CLI). METHODS: Twenty-nine patients (mean age 77.8±8.6 years; 21 men) with CLI (32 limbs) presenting with de novo infrapopliteal and pedal artery (Kawarada type 2/3) disease were reviewed. The need for PAA was based on the existence of sufficient wound blush (WB) around the target wounds after conventional above-the-ankle revascularization. Fourteen patients with insufficient WB in 14 limbs received additional PAA, while 15 patients with sufficient WB in 18 limbs did not. The groups were compared for overall survival, limb salvage, and amputation-free survival within 1 year after the procedure. The wound healing rate, time to wound healing, and freedom from reintervention rate were also evaluated. RESULT: The success rate of additional PAA was 93% (13/14). All limbs with successful PAA achieved sufficient WB (13/13). Despite insufficient WB before the additional PAA, overall survival (86% vs 73%, p=0.350), limb salvage (93% vs 83%, p=0.400), amputation-free survival (79% vs 53%, p=0.102), and freedom from reintervention (64% vs 73%, p=0.668) rates were similar in both groups. Furthermore, the wound healing rate (93% vs 60%, p=0.05) was higher and time to wound healing (86.0±18.7 vs 152.0±60.2 days, p=0.05) was shorter in the patients who received PAA. CONCLUSION: Additional PAA might improve the WB and clinical outcomes (especially speed and extent of wound healing) in patients with CLI attributed to infrapopliteal and pedal artery disease.

The impact of three-dimensional optical coherence tomography and kissing-balloon inflation for stent implantation to bifurcation lesions.

The rates of restenosis and stent thrombosis after the therapeutic stent deployment for bifurcation lesions are still comparably high after the introduction of the new-generation drug-eluting stents (DESs), because of the various factors including their morphology. We experienced a case of a successful percutaneous coronary intervention using three-dimensional optical coherence tomography (3D OCT) with a single stent deployment to a bifurcation lesion of the left anterior descending artery (LAD) and left circumflex artery (LCx) with a following kissing-balloon inflation (KBI). The 3D OCT, after the inflation of the jailed ostium of the LCx following the stent deployment to the LAD crossing the LCx, could clearly demonstrate a stent deformation and incomplete apposition at an opposite site of the LCx, which may cause high rates of restenosis and stent thrombosis. These stent abnormalities were steadily corrected by a subsequent KBI of the LAD and LCx. Furthermore, the 3D OCT images were the same findings as those of the experiments from both an in vitro phantom coronary bifurcation model and macroscopic images of the stent. .

An Autopsy Case of Two Distinct, Acquired Drug Resistance Mechanisms in Epidermal Growth Factor Receptor-mutant Lung Adenocarcinoma: Small Cell Carcinoma Transformation and Epidermal Growth Factor Receptor T790M Mutation.

We herein describe the case of a 63-year-old man who died from relapsed epidermal growth factor receptor gene (EGFR) exon 19 deletion lung adenocarcinoma treated with erlotinib. According to the autopsy results, he was confirmed to have small cell carcinoma without the EGFR T790M mutation in his pancreas and left kidney metastatic specimens, while the adenocarcinoma metastatic lesion in his right kidney had the EGFR T790M mutation; both retained the somatic EGFR exon 19 deletion. We herein report an autopsy case of resistance to an EGFR tyrosine kinase inhibitor via small cell carcinoma transformation and the EGFRT790M mutation in separate metastatic organs.

Interleukin-17A in Legionella pneumonia: a retrospective study.

Interleukin (IL)-17A affects the immune system of the lung. Legionella infection can potentially lead to severe pneumonia. The present study aimed to evaluate the role of IL-17A in Legionella pneumonia. Serum IL-17A levels were quantified in both patients with Legionella pneumonia and control subjects; IL-17 was detected in sera from 4 out of 31 patients with Legionella pneumonia but in any controls. There were no differences in peripheral white blood cell counts or other serum biomarkers (C-reactive protein, and lactate dehydrogenase) between IL-17A-positive and IL-17A-negative patients. All IL-17A-positive patients in this cohort survived, where 8 of 27 IL-17A-negative patients did not. IL-17A was detected in available bronchoalveolar (BA) fluid samples from 7 patients with Legionella pneumonia within our cohort. However, the IL-17A and IFN-γ concentrations in BA fluids did not correlate with each other. IL-17A might play a significant role in some cases of Legionella pneumonia.

Clinical evaluation of high mobility group box 1 protein in Legionella pneumophila pneumonia.

High mobility group box 1 (HMGB-1) protein is involved in acute lung injury due to various etiologies. We evaluated HMGB-1 levels in sera and bronchoalveolar fluids in patients with pneumonia caused by Legionella pneumophila. Levels of HMGB-1 in the sera of patients with L. pneumophila pneumonia (32 cases) and control subjects (24 cases) were determined. Serum HMGB-1 levels in Legionella pneumonia were similar to those of the control subjects. No significant correlation between HMGB-1 levels and other biomarkers and the outcome of cases was observed. In contrast, HMGB-1 levels, as well as interferon-γ, in bronchoalveolar (BA) fluids from severe L. pneumophila pneumonia (7 cases) were significantly higher than those in the sera of identical patients. HMGB-1 levels in BA fluids were relatively higher in pneumonia cases with ALI than those without ALI. Our findings suggest that intra-pulmonary HMGB-1 may be involved in the pathophysiology of pneumonia caused by L. pneumophila.