Impact of microvascular decompression on wall shear stress in responsible arteries in trigeminal neuralgia and hemifacial spasm.

Microvascular decompression (MVD) has proven efficacy in trigeminal neuralgia (TN) and hemifacial spasm (HFS). This study utilized computational fluid dynamics (CFD) to investigate the impact of MVD on wall shear stress (WSS) of responsible arteries (RAs) at the neurovascular contact (NVC). A total of 21 cases (10 TN, 11 HFS) were analyzed, involving RAs at NVC validated through intraoperative photographs. Hemodynamic parameters (WSS, vessel diameter, flow rate, pressure drop) was calculated using CFD for the RAs based on 3D silent-magnetic resonance angiograms. The NVC was segmented into NVC-proximal, NVC-site, and NVC-distal portions using simulated 3D CFD images that correlated with surgical observations. WSS ratios of NVC-site to NVC-proximal (NVC-site/proximal) was calculated both before and after MVD. Prior to MVD, WSS in the RA at the NVC displayed a peaked curve with a maximum at NVC-site; however, post MVD, it presented a smooth curve without peaks. The WSS ratio exhibited a significant decrease after MVD. The impact of MVD on WSS of RAs at NVC was evaluated in both TN and HFS cases. Analyzing the hemodynamics of RAs through CFD and identifying WSS peaks at NVC portions before MVD provided a more detailed and localized understanding of the morphologically depicted NVC.

Assessment of morphology and hemodynamics in a surgically clipped neck of a cerebral aneurysm: illustrative case.

BACKGROUND: Silent magnetic resonance angiography reduces metal artifacts, enabling clear visualization of the clipped neck following surgical clipping of cerebral aneurysms. This study aimed to delineate the morphology of the clipped neck complex in cerebral aneurysms using three-dimensional (3D) multifusion imaging of silent magnetic resonance angiography and fast spin echo magnetic resonance cisternography. Additionally, computational fluid dynamics analysis was utilized to evaluate the hemodynamics of the parent vessel at the clipped neck, allowing for a detailed assessment of hemodynamics at the clipped neck. OBSERVATIONS: The 3D multifusion image enabled visualization of the orientation and shape of the clip within the clipped neck complex, alongside the morphology of the parent vessel. In the hemodynamic analysis of the parent vessel at the clipped neck, areas of high-intensity magnitude of wall shear stress (WSSm) variation corresponding to the clip's contour, along with significant vector of wall shear stress (WSSv) variation related to vector directionality, were visualized in 3D. The intentional residual neck, coated with muscle grafts, was depicted as an area with low WSSm variation values and high WSSv variation values. LESSONS: Three-dimensional multifusion imaging, along with computational fluid dynamics analysis of the parent vessels, facilitated both the morphological and hemodynamic visualization and assessment of the clipped neck complex following neck clipping surgery for cerebral aneurysms. https://thejns.org/doi/10.3171/CASE24194.

Evaluation of the shrinkage process of a neck remnant after stent-coil treatment of a cerebral aneurysm using silent magnetic resonance angiography and computational fluid dynamics analysis: illustrative case.

BACKGROUND: Silent magnetic resonance angiography (MRA) mitigates metal artifacts, facilitating clear visualization of neck remnants after stent and coil embolization of cerebral aneurysms. This study aims to scrutinize hemodynamics at the neck remnant by employing silent MRA and computational fluid dynamics. OBSERVATIONS: The authors longitudinally tracked images of a partially thrombosed anterior communicating artery aneurysm's neck remnant, which had been treated with stent-assisted coil embolization, using silent MRA over a decade. Computational fluid dynamics delineated the neck remnant's reduction process, evaluating hemodynamic parameters such as flow rate, wall shear stress magnitude and vector, and streamlines. The neck remnant exhibited diminishing surface area, volume, neck size, dome depth, and aspect ratio. Its reduction correlated with a decline in the flow rate ratio of the remnant dome to the inflow parent artery. Analysis delineated regions within the contracting neck remnant characterized by consistently low average wall shear stress magnitude and variation, accompanied by notable variations in wall shear stress vector directionality. LESSONS: Evaluation of neck remnants after stent-coil embolization is possible through silent MRA and computational fluid dynamics. Predicting the neck remnant reduction may be achievable through hemodynamic parameter analysis.

Assessment of Mild Cognitive Impairment Using CogEvo: A Computerized Cognitive Function Assessment Tool.

INTRODUCTION/OBJECTIVES: To assess the utility of the computerized cognitive function assessment tool, CogEvo, as a screening tool for mild cognitive impairment in primary care, we explored the relationship between CogEvo performance, age, and the severity of cognitive dysfunction evaluated by the Mini-Mental State Examination (MMSE). METHODS: The observational cross-sectional study included 209 individuals' data (mean age 79.4 ± 8.9 years). We conducted a correlation analysis between CogEvo and MMSE scores, compared the performance among the 3 cognitive function groups (MMSE ≥ 28 group; MMSE24-27 group; MMSE ≤ 23 group) using the MMSE cut-off, and evaluated CogEvo's predictive accuracy for cognitive dysfunction through ROC analysis. RESULTS: Both total CogEvo and MMSE scores significantly decreased with age. A significant positive correlation was observed between total CogEvo and MMSE scores, but a ceiling effect was detected in MMSE performance. Significant differences were observed in the total CogEvo score, including orientation and spatial cognitive function scores, among the 3 groups. CogEvo showed no educational bias. ROC analyses indicated moderate discrimination between the MMSE ≥ 28 group and the MMSE24-27 and MMSE ≤ 23 groups. CONCLUSIONS: The computer-administered CogEvo has the advantage of not exhibiting ceiling effects or educational bias like the MMSE, and was found to be able to detect age-related cognitive decline and impairment.

Computational Fluid Dynamics Analysis of Trigeminal Neuralgia Associated with the Vertebral Artery: A Report of Two Cases.

Trigeminal neuralgia is a nerve disorder that causes unilateral severe facial pain. The clinical features of trigeminal neuralgia are agonizing, paroxysmal, anticipated in one or more divisions of the trigeminal nerve, with repetitive bursts of a few seconds, exacerbated by cutaneous stimuli. Microvascular decompression is proven effective, resulting in a positive outcome. Here, we report two cases of trigeminal neuralgia associated with the vertebral artery, who underwent endoscopic microvascular decompression. This case report aims to show the benefit of computational fluid dynamics evaluation of the neurovascular contact and its effect on change in wall shear stress magnitude of the offending vertebral artery after surgical management with microvascular decompression.

Pulmonary artery pressure-perfusion relation during exercise in patients with chronic thromboembolic pulmonary hypertension using pulmonary arteriography and right-heart catheterization.

Background: In pulmonary hypertension (PH), pulmonary artery pressure (PAP) does not increase to pulmonary perfusion (PP) < 50%. During exercise, PAP may be increased even at PP > 50% for the early detection of PP disorders. The relationship between PP estimated by pulmonary angiography (PAG) and PAP was evaluated in patients with chronic thromboembolic PH (CTEPH) treated by balloon pulmonary angioplasty with near-normal PH. Methods: Thirty-one patients (age 60 ± 11 years) with CTEPH underwent catheterization at rest and during exercise. Each segmental PP was determined by visualization of its segmental pulmonary artery and graded from 0 to 3 in the PAG. PP was estimated as the percentage PAG (%PAG) score-%summed total of all segmental PP/the full score-54. Results: The mean PAP (mPAP) increased from 28 ± 6 mmHg to 46 ± 10 mmHg during exercise. Transpulmonary pressure gradient, the value of mPAP with the pulmonary artery wedge pressure substituted at peak exercise, was negatively correlated with %PAG score (rs = -0.56, p < 0.001) and elevated at > 50% PP. Conclusions: The PAP-PP relationship at peak exercise was correlated, shifting from the relationship at rest, and the PAP started to rise with PP > 50%.

Transition from Intravenous Epoprostenol to Treprostinil Due to Intolerable Side Effects in Patients With Pulmonary Arterial Hypertension.

Intravenous epoprostenol improves exercise capacity and survival in patients with pulmonary arterial hypertension (PAH); however, it has side effects. Reviewing the side effects associated with epoprostenol and treprostinil is essential for improving the long-term treatment strategies for PAH. This retrospective review included patients with PAH who transitioned from intravenous epoprostenol to intravenous treprostinil owing to intolerable side effects, including high cardiac output symptoms, ascites, and thrombocytopenia. Of the 85 patients who received epoprostenol at our hospital between 2013 and 2021, 16 (11 women), with a median age of 33 (range 26 to 40) years (including 12 with idiopathic PAH, 3 with hereditary PAH, and 1 with connective tissue disease pulmonary hypertension), had to switch from intravenous epoprostenol to treprostinil owing to the side effects. After transitioning, epoprostenol-associated intolerable side effects, such as high cardiac output symptoms, ascites, and thrombocytopenia, were ameliorated. In conclusion, for patients with PAH who have intolerable side effects from epoprostenol and have difficulty in continuing treatment, switching from epoprostenol to treprostinil may be an option. Switching treatment leads to better adherence and improved long-term prostacyclin therapy.

Predicting readmission for heart failure patients by echocardiographic assessment of elevated left atrial pressure.

BACKGROUND: Pathophysiologically, an elevated left ventricular (LV) filling pressure is the major reason for heart failure (HF) readmission. The 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines provide a simplified algorithm for the echocardiographic assessment of LV filling pressure; however, this algorithm is yet to be sufficiently validated. MATERIALS AND METHODS: We retrospectively studied 139 consecutive patients with acute decompensated HF. High estimated left atrial pressure (eLAP) was defined according to the 2016 ASE/EACVI guidelines. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors for HF readmission within one year of discharge. RESULTS: Across the study cohort, 68 patients (49%) did not have a high eLAP, 32 (23%) had an indeterminate eLAP, and 39 (28%) had a high eLAP. The number of HF readmission events within one year in the without high eLAP, indeterminate, and high eLAP groups were 4 (7.5%), 5 (18.5%), and 10 (33.3%), respectively. The HF readmission rate was significantly higher in patients with high eLAP than in those without high eLAP. Multivariate analysis revealed high eLAP (odds ratio, 5.924; 95% confidence interval, 1.664-21.087; P = 0.006) as a significant risk factor for HF readmission within one year. Furthermore, the exploratory analysis of the two-year outcomes revealed a similar finding: patients with high eLAP had a significantly higher rate of readmission for HF. CONCLUSIONS: The present study demonstrated that echocardiographic assessment of elevated LAP based on the 2016 ASE/EACVI guidelines is clinically valid for predicting readmission in patients with HF.

Exercise Capacity and Ventilatory Efficiency in Patients With Pulmonary Arterial Hypertension.

Background The symptom for identification of pulmonary arterial hypertension (PAH) is dyspnea on exertion, with a concomitant decrease in exercise capacity. Even patients with hemodynamically improved PAH may have impaired exercise tolerance; however, the effect of central and peripheral factors on exercise tolerance remains unclear. We explored the factors contributing to exercise capacity and ventilatory efficiency in patients with hemodynamically normalized PAH after medical treatment. Methods and Results In total, 82 patients with PAH (age: median 46 [interquartile range, 39-51] years; male:female, 23:59) and mean pulmonary arterial pressure ≤30 mm Hg at rest were enrolled. The exercise capacity, indicated by the 6-minute walk distance and peak oxygen consumption, and the ventilatory efficiency, indicated by the minute ventilation versus carbon dioxide output slope, were assessed using cardiopulmonary exercise testing with a right heart catheter. The mean pulmonary arterial pressure was 21 (17-25) mm Hg, and the 6-minute walk distance was 530 (458-565) m, whereas the peak oxygen consumption was 18.8 (14.8-21.6) mLꞏmin-1ꞏkg-1. The multivariate model that best predicted 6-minute walk distance included peak arterial mixed venous oxygen content difference (ß=0.46, P<0.001), whereas the best peak oxygen consumption predictors included peak cardiac output (ß=0.72, P<0.001), peak arterial mixed venous oxygen content difference (ß=0.56, P<0.001), and resting mean pulmonary arterial pressure (ß=-0.25, P=0.026). The parameter that best predicted minute ventilation versus carbon dioxide output slope was the resting mean pulmonary arterial pressure (ß=0.35, P=0.041). Quadriceps muscle strength was moderately correlated with exercise capacity (6-minute walk distance; ρ=0.57, P<0.001; peak oxygen consumption: ρ=0.56, P<0.001) and weakly correlated with ventilatory efficiency (ρ=-0.32, P=0.007). Conclusions Central and peripheral factors are closely related to impaired exercise tolerance in patients with hemodynamically normalized PAH.

Trigeminal neuralgia caused by a persistent primitive trigeminal artery: preoperative three-dimensional multifusion imaging and computational fluid dynamics analysis. Illustrative case.

BACKGROUND: Trigeminal neuralgia (TN) is caused by trigeminal nerve compression by colliding vessels. Preoperative three-dimensional (3D) multifusion images are useful for surgical simulations. Moreover, computational fluid dynamics (CFD) analysis of colliding vessels may be useful for hemodynamic evaluation at the site of neurovascular contact (NVC). OBSERVATIONS: A 71-year-old woman had TN due to compression of the trigeminal nerve by the superior cerebellar artery (SCA) fused with the persistent primitive trigeminal artery (PTA). Preoperative 3D multifusion simulation images of silent magnetic resonance (MR) angiography and MR cisternography depicted the NVC, including the trigeminal nerve, SCA, and PTA. CFD analysis revealed the hemodynamic condition of the NVC, including the SCA and PTA. The wall shear stress magnitude (WSSm) at the NVC showed a local elevation due to flow confluence from the SCA and PTA. High WSSm was observed in the NVC. LESSONS: Preoperative simulation images of MR angiography and MR cisternography may depict the NVC. CFD analysis can provide the hemodynamic condition at the NVC.

Characteristics of cardiopulmonary exercise testing in patients with combined post- and pre-capillary pulmonary hypertension due to left heart disease.

BACKGROUND: Pulmonary hypertension (PH) is a common and morbid complication of left heart disease (LHD), comprising two subtypes: (1) isolated post-capillary pulmonary hypertension (Ipc-PH) and (2) combined post-capillary and pre-capillary pulmonary hypertension (Cpc-PH). Knowledge regarding the physiological characteristics that distinguish Cpc-PH, which has a worse prognosis, from Ipc-PH remains limited. Therefore, this study aimed to assess the utility of cardiopulmonary exercise testing (CPET) variables in detecting Cpc-PH. METHODS AND RESULTS: Among 105 consecutive patients with LHD (age: 55 ± 13 years; male/female = 79/26) who underwent right heart catheterization and CPET, 45 (43%) were classified as PH-LHD (mean pulmonary artery pressure >20 mmHg). Ipc-PH (n = 24) was defined as pulmonary vascular resistance (PVR) ≤ 3 WU and Cpc-PH (n = 21) as PVR > 3 WU. Patients with Cpc-PH had a significantly lower peak partial pressure of carbon dioxide (PETCO2) (Non-PH/Ipc-PH/Cpc-PH = 38.2 ± 6.6 vs. 38.3 ± 6.0 vs 33.0 ± 4.4 mmHg, p = 0.006), higher VE vs. VCO2 slope (Non-PH/Ipc-PH/Cpc-PH = 33.0 [28.3, 36.6] vs. 32.5 [28.1, 37.8] vs. 40.6 [33.6, 46.1], p = 0.007), and lower ΔVO2/ΔWR (Non-PH/Ipc-PH/Cpc-PH = 8.5 ± 1.4 vs. 8.0 ± 1.7 vs. 6.8 ± 2.0 mL/min/watt, p = 0.001) than those with Ipc-PH and non-PH. Using multivariable logistic regression analysis, CPET variables were found to be independent predictors of Cpc-PH (lower peak PETCO2: odds ratio, 0.728 [95% confidence interval {CI}: 0.616-0.840], p = 0.003 and lower ΔVO2/ΔWR: odds ratio, 0.747 [95% CI: 0.575-0.872], p = 0.003). CONCLUSION: From our exploratory analysis, CPET variables, especially in the lower peak PETCO2 and lower ΔVO2/ΔWR, were associated with Cpc-PH in patients with left heart disease.

Comparison of the prognostic value of lateral versus septal early mitral annulus velocity in patients with acute decompensated heart failure.

Mitral annular early diastolic velocity (e') measured using Doppler echocardiography is important for the noninvasive estimation of left ventricular filling pressure (LVFP). However, it remains unknown whether lateral or septal e' is prognostically more reliable. Accordingly, here, we compared the prognostic utility of lateral e' with that of septal e' in patients hospitalized for acute decompensated heart failure (HF). We retrospectively analyzed the data of 193 consecutive patients with acute decompensated HF. According to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines, the cut-off values of high lateral e' and septal e' were 10 cm/s and 7 cm/s, respectively. Kaplan-Meier survival curves and log-rank tests were used to compare 90-day mortality between groups. For the entire cohort, 90-day mortality was 15.5%. Lateral e' <10 was significantly correlated with higher 90-day mortality (log-rank, P = 0.026), whereas septal e' <7 was not significantly associated with 90-day mortality (log-rank, P = 0.405). Receiver operating characteristic curve analyses revealed that the best cut-off values for lateral e' and septal e' in this cohort were 10 cm/s and 6 cm/s, respectively. However, septal e' <6 was also not associated with 90-day mortality (log-rank, P = 0.141). This study demonstrated that, when comparing lateral e' with septal e', the former provides better prognostic utility for patients with acute decompensated HF. If a dissociation between lateral e' and septal e' is detected, the value measured at the lateral site may be more credible for determining LVFP in HF.

Validity and reliability of a computerized cognitive function evaluation battery (CogEvo) as a screening tool.

Aim: The aim of this study was to determine the validity and reliability of cognitive function evaluation battery, CogEvo, a recently developed computerized cognitive function evaluation battery, as a screening tool for decreased cognitive function. Methods: The study sample comprised 123 (age: 57-97 years) community-dwelling elderly people. They were required to perform five CogEvo tasks and complete two questions-based neuropsychological tests, including the Mini-Mental State Examination, so that the correlations could be analyzed. The validity and reliability of CogEvo were examined using factor analysis, MacDonald's omega reliability coefficient, logistic regression analysis, and receiver operating characteristic curve analysis. Results: Exploratory factor analysis revealed the orientation/spatial cognitive function (orientation and spatial cognition) and attention/executive function (attention, memory, and execution) factors. Structural validity was supported by confirmatory factor analysis. All two-factor-based subtasks showed adequate internal consistency (MacDonald's omega ≥0.6). The total CogEvo score and two-factor scores were significantly correlated with neuropsychological test results. Based on the total CogEvo score, the cognitively normal and cognitive decline groups were identified by receiver operating characteristic curve analysis with a moderate predictive performance. The cognitive decline group was well identified using the orientation/spatial cognitive function factor. Conclusions: CogEvo is a valid and reliable screening tool for cognitive function evaluation. It proved useful in the early identification of cognitive decline in our study sample.

Correlation between CT Value on Lung Subtraction CT and Radioactive Count on Perfusion Lung Single Photon Emission CT in Chronic Thromboembolic Pulmonary Hypertension.

Background: Lung subtraction CT (LSCT), the subtraction of noncontrast CT from CT pulmonary angiography (CTPA) without spatial misregistration, is easily applicable by utilizing a software-based deformable image registration technique without additional hardware and permits the evaluation of lung perfusion as iodine accumulation, similar to that observed in perfusion lung single photon emission CT (PL-SPECT). The aim of this study was to use LSCT to newly assess the quantitative correlation between the CT value on LSCT and radioactive count on PL-SPECT as a reference and validate the quantification of lung perfusion by measuring the CT value in chronic thromboembolic pulmonary hypertension (CTEPH). Methods: We prospectively enrolled 47 consecutive patients with CTEPH undergoing both LSCT and PL-SPECT; we used noncontrast CT, CTPA, and LSCT to measure CT values and PL-SPECT to measure radioactive counts in areas representing three different perfusion classes­no perfusion defect, subsegmental perfusion defect, and segmental perfusion defect; we compared CT values on noncontrast CT, CTPA, and LSCT and radioactive counts on PL-SPECT among the three classes, then assessed the correlation between them. Results: Both the CT values and radioactive counts differed significantly among the three classes (p < 0.01 for all) and showed weak correlation (ρ = 0.38) by noncontrast CT, moderate correlation (ρ = 0.61) by CTPA, and strong correlation (ρ = 0.76) by LSCT. Conclusions: The CT value measurement on LSCT is a novel quantitative approach to assess lung perfusion in CTEPH and only correlates strongly with radioactive count measurement on PL-SPECT.

EmPHasis-10 Health-Related Quality of Life and Exercise Capacity in Chronic Thromboembolic Pulmonary Hypertension After Balloon Angioplasty.

Background Whether pulmonary hemodynamic parameters and functional capacity are associated with quality of life in patients with chronic thromboembolic pulmonary hypertension remains unknown. This study aimed to evaluate disease-specific quality of life using the emPHasis-10 questionnaire and assess its determinants in patients with chronic thromboembolic pulmonary hypertension with normalized pulmonary hemodynamics. Methods and Results This cross-sectional study included 187 health status assessments of 143 patients with chronic thromboembolic pulmonary hypertension (median age, 68 [58-75] years; men/women, 51/136; use of home oxygen therapy, 51 patients [27%]) after balloon pulmonary angioplasty with normalized mean pulmonary artery pressure <25 mm Hg at rest. Right heart catheterization was performed, followed by assessment of 6-minute walk distance and the emPHasis-10 questionnaire. The median pulmonary artery pressure and pulmonary vascular resistance were 18 (15-21) mm Hg and 2.2 (1.7-2.9) wood units, respectively. The median emPHasis-10 score was 14 (8-24), whereas the median 6-minute walk distance was 447 (385-517) m. Univariate linear regression analysis showed that the emPHasis-10 score was associated with 6-minute walk distance (ß=-0.476 [95% CI -0.604, -0.348], P<0.001) and home oxygen therapy (ß=0.214 [95% CI, 0.072, 0.356], P=0.003) but not with hemodynamic parameters. Multiple regression analysis revealed that a higher emPHasis-10 score was associated with lower 6-minute walk distance (ß=-0.475 [95% CI, -0.631 to -0.319], P<0.001). Conclusions Health-related quality of life was associated with exercise capacity and the use of home oxygen therapy, but not with hemodynamic parameters, in patients with chronic thromboembolic pulmonary hypertension and normalized hemodynamics after balloon pulmonary angioplasty. Improvements in exercise capacity may lead to further improvements in quality of life.

Reversible Cardiac Hypertrophy in Pulmonary Arterial Hypertension Treated With High-Dose Epoprostenol.

Although current guidelines recommend the use of prostanoid infusion that includes epoprostenol for high-risk pulmonary arterial hypertension patients, epoprostenol has many adverse effects. We report a case of a heritable pulmonary arterial hypertension patient who had transient biventricular hypertrophy during high-dose administration of epoprostenol. In this case, biventricular hypertrophy with worsening of dyspnea was observed during the uptitration of epoprostenol. Inflammatory diseases and endocrine disorders were ruled out as causes of the ventricular hypertrophy. After epoprostenol was changed to intravenous treprostinil, the biventricular hypertrophy normalized, in connection with dyspnea improvement. The use of high-dose epoprostenol may contribute to cardiac hypertrophy.

Bien que les lignes directrices en vigueur recommandent les perfusions de prostanoïdes comprenant de l'époprosténol chez les patients à risque élevé atteints d'hypertension artérielle pulmonaire, les effets indésirables de l'époprosténol sont nombreux. Nous décrivons ici le cas d'un patient atteint d'hypertension artérielle pulmonaire héréditaire ayant présenté une hypertrophie biventriculaire transitoire pendant le traitement par de l'époprosténol à dose élevée. Pour ce patient, une hypertrophie biventriculaire accompagnée d'une aggravation des symptômes de dyspnée ont été observées lors de l'ajustement à la hausse de la dose d'époprosténol. Les maladies inflammatoires et les troubles endocriniens ont été écartés comme facteurs étiologiques de l'hypertrophie ventriculaire. Après le remplacement de l'époprosténol par du tréprostinil intraveineux, l'hypertrophie biventriculaire s'est résorbée, et les symptômes de dyspnée se sont atténués. Il semble donc que l'utilisation de l'époprosténol à dose élevée puisse contribuer à l'hypertrophie cardiaque.

Hemifacial spasm due to vertebral artery dissecting aneurysm treated with stent-in-stent placement; Pre- and post-treatment evaluation by 3D multifusion imaging using silent MR angiography.

Background: Hemifacial spasm (HFS) due to vertebral artery (VA) dissecting aneurysm (VADA) is rare and endovascular treatment has been performed in selected cases. Case Description: We encountered a case of HFS caused by VADA that was managed with endovascular stent placement and additional stent-in-stent placement. Therapeutic strategies and benefits based on pre- and post-treatment evaluation by 3D multifusion imaging using silent MRA were discussed. Conclusion: This is the first case report of stent-in-stent placement in successful treatment of HFS caused by VADA, in which relief of neurovascular contact was demonstrated by multifusion imaging.

Long-term safety of a structured transition protocol from parenteral prostanoids to selexipag in pulmonary arterial hypertension.

There was no structured method for safely transition from parenteral prostanoids to oral medication. We enrolled 37 idiopathic/hereditary pulmonary arterial hypertension patients receiving triple combination therapy including parenteral prostanoids into structured transition program to oral selexipag. Four (10.8%) patients successfully transitioned under the protocol, and all of them presented long-term safety.