Comparison of survival times of advanced cancer patients with palliative care at home and in hospital.

OBJECTIVES: One primary concern about receiving care at home is that survival might be shortened because the quality and quantity of treatment provided at home will be inferior to that given in the hospital. Although our previous study demonstrated a longer survival of those with home-based palliative care (PC), it lacked adjustment for some potential confounders including symptoms and treatments during the stay. We aimed to compare the survival times among advanced cancer patients receiving home-based and hospital-based PC with adjusting for symptoms and treatments. METHOD: We compared survival time of participants who enrolled two multicenter, prospective cohort studies of advanced cancer patients at 45-home-based PC services between July 2017 and December 2017, and at 23-hospital-based PC services between January 2017 and December 2017. We analyzed with stratification by the estimated survival of Days, Weeks, and Months, which were defined by modified Prognosis in Palliative care Study predictor models-A. We conducted a Cox regression analysis with adjusting for potential confounders including symptoms and treatments during the stay. RESULTS: A total of 2,998 patients were enrolled in both studies and 2,878 patients were analyzed; 988 patients receiving home-based PC and 1,890 receiving hospital-based PC. The survival time of patients receiving home-based PC was significantly longer than that of patients receiving hospital-based PC for the Days Prognosis (estimated median survival time: 10 days [95% CI 8.1-11.8] vs. 9 days [95% CI 8.3-10.4], p = 0.157), the Weeks prognosis (32 days [95% CI 28.9-35.4] vs. 22 days [95% CI 20.3-22.9], p < 0.001), and the Months Prognosis, (65 days [95% CI 58.2-73.2] vs. 32 days [95% CI 28.9-35.4], p < 0.001). CONCLUSION: In this cohort of advanced cancer patients with a Weeks or Months prognosis, those receiving home-based PC survived longer than those receiving hospital-based PC after adjusting for symptoms and treatments.

Inquiry into short-term learning on Japanese rural islands: a qualitative study.

BACKGROUND: Community-based medical education (CBME) improves the learning of medical students. The outcomes depend on the circumstances in which students learn. So far, there has been no study on the short-term learning experienced by medical students on rural islands in Japan; hence, we specifically explored this in the case of islands in Okinawa. METHODS: We conducted one-on-one semi-structured interviews with seven medical students and three focus groups, each comprising three medical students. All subjects underwent a three-day clinical training on the rural islands of Okinawa, Japan. All sessions were audio-recorded and transcribed verbatim. We analysed the contents of the interview using the Steps for Coding and Theorisation. RESULTS: Ten concepts were extracted and four themes generated: 1) rural resources and environments, 2) interaction with inhabitants, 3) rural physicians' skills, and 4) proposed revisions. These themes and concepts provide valuable insights into the dynamics of medical care on rural islands as well as the benefit of this experience for students trained in urban contexts. The participants learned the importance of collaborating with multiple professionals in ways specific to each rural context. By interacting with various islanders, they developed an understanding of the different cultural backgrounds in which rural physicians work and their ability to adapt to each. This experience motivated them to pursue studies on rural medicine upon return to the mainland. CONCLUSION: This study shows that a short-term learning experience on rural islands in Japan may help medical students understand specific rural resources and their importance, the interconnections among the inhabitants, and the competency of primary care physicians.

Anatomical predisposing factors of transmural thermal injury after pulmonary vein isolation.

Aims: Transmural thermal injury (TTI), such as oesophageal erosion/ulcer and perioesophageal nerve injury leading to gastric hypomotility, is an important complication associated with pulmonary vein isolation (PVI). However, a predictor of TTI concerning anatomical structures surrounding the oesophagus has not yet been fully elucidated. Therefore, we sought to identify the predisposing factors of TTI after PVI. Methods and results: Consecutive 110 patients, who underwent PVI for atrial fibrillation, received oesophagogastroduodenoscopy 2 days later, were investigated. The relationships between TTI and clinical and anatomical parameters were examined. Based on the computed tomography data, we measured the angle of the left atrial (LA) posterior wall to the descending aorta (Ao) (LA-Ao angle), the branching angle of the left inferior pulmonary vein (LIPV) to the coronal plane (LIPV angle), and the minimum distance between the LA posterior wall and descending Ao enclosing the oesophagus (LA-Ao distance). Transmural thermal injuries occurred in 21 patients (oesophageal erosion in 5 and gastric hypomotility in 16). Age, gender, body mass index, LA diameter, and LA volume index in echocardiography were not associated with TTI. However, the LIPV angle was larger and the LA-Ao distance was shorter in the TTI (+) group compared to the TTI (-) group. With multivariate logistic regression analysis, the LIPV angle [odds ratio (OR): 2.144, P = 0.0031] and LA-Ao distance (OR: 0.392, P = 0.0229) were independent predictors of TTI. Conclusion: The anatomical proximities of the LA posterior wall, LIPV, and descending Ao surrounding the oesophagus are strongly associated with the prevalence of TTI.

Crucial role of pulmonary vein firing as an initiator of typical atrial flutter: Evidence of a close relationship between atrial fibrillation and typical atrial flutter.

BACKGROUND: Several studies reported that cavotricuspid isthmus-dependent atrial flutter (typical AFL) frequently coexists with atrial fibrillation (AF); however, the underlying mechanisms have not been fully investigated. This study aimed to reveal the mechanisms of the initiation of typical AFL and the association between typical AFL and AF. METHODS: Among 154 consecutive patients undergoing a first catheter ablation of AF, we investigated the appearance and mechanism of spontaneous initiation of typical AFL during catheter ablation. Then, we retrospectively investigated 67 consecutive patients without a previous AF episode who underwent typical AFL ablation. The occurrence and predictors of AF after catheter ablation were evaluated. RESULTS: During AF ablation, spontaneous initiation of typical AFL occurred during sinus rhythm in eight (5.2%) patients. The initiations of typical AFL were pulmonary vein (PV) firings except in one patient, in whom paroxysmal AF following superior vena cava firing initiated reverse typical AFL after PV isolation. After typical AFL ablation, AF occurred in 23 (34.3%) patients (mean follow up, 28.2±20.3 months). Kaplan-Meier analysis showed the occurrence of AF after typical AFL ablation to be significantly higher in the patients with a larger left atrial diameter over 40 mm (log-rank test, P=0.046). CONCLUSIONS: PV firing through AF played an important role in initiating typical AFL. The occurrence of AF after typical AFL ablation was high, and a dilated left atrium was associated with increased occurrence of AF. These findings disclosed the close relationship between typical AFL and AF, especially PV firing.

Intracardiac impedance after cardiac resynchronization therapy is a novel predictor for worsening of heart failure.

Intrathoracic impedance measured by cardiac resynchronization therapy (CRT) varies because several factors other than pulmonary congestion may affect this parameter. Therefore, we hypothesized that changes in intracardiac impedance between the right and left ventricular leads would be more accurate to identify worsening heart failure in patients with CRT. The study enrolled 21 patients with CRT defibrillator (15 males, 70 ± 12 years). During the follow-up period (12 ± 7 months), the subjects experienced 37 fluid index threshold (60 ohm-days) crossing events. These events were divided into two groups whether hospitalization due to worsening heart failure was required (group-H, n = 14) or not (group-NH, n = 23). Based on the intracardiac impedance at the beginning of increasing fluid index (BI) and the crossing of 60 ohm-days (CI), the rate of impedance change (BI-CI/BI) was estimated. Then, the time elapsed from BI to CI (T) was evaluated. We calculated the rate of intracardiac impedance change per day (BI-CI/BI × T) in each group. The rate of intrathoracic impedance change per day was also determined using the same method. The median rate of intracardiac impedance change per day was 0.27 (IQR 0.22-0.54) %/day in group-H, and 0 (IQR 0-0.08) %/day in group-NH with a significant difference (P < 0.0001), whereas the rate of intrathoracic impedance change per day was similar between the two groups. By receiver operating characteristic curve for identification of hospitalization due to worsening heart failure, the best cutoff value of the rate of intracardiac impedance change per day was 0.20%/day (sensitivity 92%, specificity 88%, and AUC 0.98). In contrast, the best cutoff value of the rate of intrathoracic impedance change per day was 0.19%/day (sensitivity 86%, specificity 43%, and AUC 0.68). These results suggest that increased rate of change of decreasing intracardiac impedance measured by CRT is a novel useful predictor for worsening heart failure.

Fibrillatory excitation in the pulmonary vein is associated with the presence of dissociated pulmonary vein activity after isolation.

PURPOSE: Circumferential pulmonary vein (PV) isolation has been widely accepted for catheter ablation in patients with atrial fibrillation (AF). Dissociated PV activity might appear after PV isolation (PVI). However, little is known of dissociated PV activity. This study aimed to reveal the electrophysiological properties and clinical implications of dissociated PV activity. METHODS: The study subjects were 52 patients (62 ± 7 years, 38 men) who underwent PVI for AF. Electrophysiological properties of the left atrium (LA) and PVs during and after PVI were investigated. RESULTS: Out of 181 targeted PVs, 177 with successful isolation were analyzed. Dissociated PV activity appeared in 14 PVs (8 %) in 12 patients (23 %) after PVI; from the left superior PV in eight, right superior PV in five, and left inferior PV in one. The mean cycle length of dissociated PV activity was 4277 ± 2565 ms. The presence of AF prior to achieving PVI was significantly higher in PV without dissociated PV activity (105 out of 163, 64 %) than in PV with dissociated PV activity (five out of 14, 36 %, P = 0.03). The observed dissociated PV activity was enhanced (new appearance or reduced cycle length) by isoproterenol and suppressed by pacing within the isolated PV. CONCLUSION: Dissociated PV activity, although influenced by uncertain factors such as overdrive suppression and autonomic situations, would be an indicator of LA-PV bidirectional block and might not be the target of additional ablation after PVI.

Mapping Strategy Associated with QRS Morphology for Catheter Ablation in Patients with Idiopathic Ventricular Outflow Tract Tachyarrhythmia.

BACKGROUND: In catheter ablation of idiopathic ventricular arrhythmia (VA), it is still unclear whether pace mapping or activation mapping is more useful for successful catheter ablation. The depth of origin in the ventricular wall especially affects the success rate of endocardial-approached catheter ablation. Thus, we examined the relationship between these tactics and QRS morphology. METHODS: We evaluated the relationship among pace mapping score, activation time, and peak deflection index (PDI) in 28 patients, with a total of 30 origins, who underwent successful catheter ablation of idiopathic VA. RESULTS: All origins were located in the ventricular outflow tract area, including three in the left coronary cusp (LCC). PDI, activation time, and pace mapping score at successful ablation sites were 0.60 ± 0.08, 26.3 ± 9.9 ms, and 19.1 ± 4.6, respectively. The pace mapping score inversely correlated with the PDI (R = -0.540, P = 0.0017), but the activation time did not correlate with the PDI. When excluding the three VAs originating from the LCC, in which perfect pace mapping was obtained from epicardial sites despite high PDI, this correlation coefficient became more intensive (R = -0.734, P < 0.0001). CONCLUSIONS: Our study suggests that pace mapping with an endocardial approach could not reproduce the precise QRS morphology for VA originating from the intramural site of the ventricular wall. With such origins, we should rely on activation mapping to detect the optimal ablation site.

Association of Serum n-3/n-6 Polyunsaturated Fatty Acid Ratio With T-Wave Alternans in Patients With Ischemic Heart Disease.

Several studies have demonstrated that oral intake of n-3 polyunsaturated fatty acids, specifically eicosapentaenoic acid (EPA), prevents ventricular tachyarrhythmias (VT) with ischemic heart disease, but the underlying mechanisms still remain unclear. Thus, we examined the relation between the serum EPA/arachidonic acid (AA) ratio and electrophysiological properties in patients with ischemic heart disease. The study subjects consisted of 57 patients (46 males, mean age, 66 ± 13 years) with ischemic heart disease. T-wave alternans (TWA) and heart rate variability were assessed by 24hour Holter ECG, and left ventricular ejection fraction (LVEF) was determined by echocardiography. Fasting blood samples were collected, and the serum EPA/AA ratio was determined. Based on a median value of the serum EPA/AA ratio, all subjects were divided into two groups: serum EPA/AA ratio below 0.33 (Group-L, n = 28) or not (Group-H, n = 29). We compared these parameters between the two groups. LVEF was not different between the two groups. The maximum value of TWA was significantly higher in Group-L than in Group-H (69.5 ± 22.8 µV versus 48.7 ± 12.0 µV, P = 0.007). In addition, VT defined as above 3 beats was observed in 7 cases (25%) in Group-L, but there were no cases of VT in Group-H (P = 0.004). However, low-frequency (LF) component, high-frequency (HF) component, LF to HF ratio, and standard deviation of all R-R intervals were not different between the two groups. These results suggest that a low EPA/AA ratio may induce cardiac electrical instability, but not autonomic nervous imbalance, associated with VT in patients with ischemic heart disease.

Serum phosphate levels reflect responses to cardiac resynchronization therapy in chronic heart failure patients.

BACKGROUND: Recent studies have shown that high levels of serum phosphate are associated with adverse cardiovascular events. However, little is known about the relation between phosphate levels and improvement of cardiac function in chronic heart failure (CHF) patients who underwent cardiac resynchronization therapy (CRT). The purpose of this study was to examine whether serum phosphate levels were able to predict responders to CRT and adverse cardiac events. METHODS: The study population consisted of 30 CHF patients (24 males, mean age 65.7±8.5 years) who received CRT with defibrillator (CRT-D) implantation. Levels of serum phosphate were measured before, and 6 months after, CRT-D implantation. Left ventricular end-diastolic volume and end-systolic volume were assessed simultaneously by echocardiography. In addition, the rate of re-hospitalization due to worsening of heart failure was investigated. All patients were divided into 2 groups: responders (Group-R, n=18) and non-responders (Group-NR, n=12) to CRT-D. Responders were defined as patients who showed >15% reduction in left ventricular end-systolic volume. We compared these parameters between the 2 groups. RESULTS: Serum phosphate levels were significantly lower in Group-R than in Group-NR (3.3±0.2 vs. 3.7±0.4 mg/dL, p=0.01). The rate of re-hospitalization was lower in Group-R than in Group-NR (0% vs. 33%, p=0.018). Multivariate analysis showed that serum phosphate levels had a predictive power to determine responders to CRT (odds ratio 0.008, 95% confidence interval 0.000-0.348, p=0.015). CONCLUSIONS: These results suggest that serum phosphate levels might predict both responders to CRT, and adverse cardiac events, in CHF patients with CRT-D.

Predictive impact of the decreasing rate of intrathoracic impedance in worsening chronic heart failure.

PURPOSE: Intrathoracic impedance monitoring is useful for heart failure (HF) management in patients with cardiac resynchronization therapy (CRT). However, more accurate identification of worsening chronic HF (CHF) is required in the clinical setting. We investigated this issue by estimating changes in impedance. METHODS: We studied 38 CHF patients (29 males, mean age 67 years) with CRT-defibrillator capable of impedance monitoring. During the follow-up period (20.7 ± 7.8 months), the subjects experienced a total of 129 fluid index threshold (60 ohm·days) crossing events. These events were divided into two groups: HF events (n = 70) and no HF events (n = 59). Based on the impedance at the beginning of increasing fluid index (S) and at the crossing of 60 ohm·days (E), the rate of impedance change (S - E / S) was estimated. In addition, the elapsed time from S to E (T) was evaluated. Then, we calculated the rate of impedance change per day (S - E / S × T) in each group. RESULTS: The rate of impedance change per day was significantly higher in HF events than in no HF events (0.86 ± 0.48 vs. 0.37 ± 0.22%/day, P < 0.01). By receiver operating characteristic curve for identification of HF events, the best cutoff value of the rate of impedance change was 0.48%/day (sensitivity 80%, specificity 81%, and area under the curve 0.85). CONCLUSIONS: These results suggest that a faster drop in intrathoracic impedance reflected worsening CHF in patients with CRT-defibrillator. Thus, intrathoracic impedance monitoring based on the rate of impedance change may provide a more accurate identification of worsening CHF.

Efficacy of intrathoracic impedance and remote monitoring in patients with an implantable device after the 2011 great East Japan earthquake.

Several studies have revealed that stress after catastrophic disasters can trigger cardiovascular events, however, little is known about its association with the occurrence of heart failure in past earthquakes. The objective of the present study was to determine whether the Great East Japan Earthquake on March 11, 2011, increased the incidence of worsening heart failure in chronic heart failure (CHF) patients with implantable devices. Furthermore, we examined whether intrathoracic impedance using remote monitoring was effective for the management of CHF.We enrolled 44 CHF patients (32 males, mean age 63 ± 12 years) with implantable devices that can check intrathoracic impedance using remote monitoring. We defined the worsening heart failure as accumulated impedance under reference impedance exceeding 60 ohms-days (fluid index threshold), and compared the incidence of worsening heart failure and arrhythmic events 30 days before and after March 11.Within the 30 days after March 11, 10 patients exceeded the threshold compared with only 2 patients in the preceding 30 days (P < 0.05). Although 9 patients using remote monitoring among the 10 patients with threshold crossings were not hospitalized, one patient without the system was hospitalized due to acute decompensated heart failure. On the contrary, arrhythmic events did not change between before and after March 11.Our results suggest that earthquake-induced stress causes an increased risk of worsening heart failure without changes in arrhythmia. Furthermore, intrathoracic impedance using remote monitoring may be a useful tool for the management of CHF in catastrophic disasters.

Sleep-disordered breathing increases risk for fatal ventricular arrhythmias in patients with chronic heart failure.

BACKGROUND: It has been shown that sleep-disordered breathing (SDB) is associated with adverse prognosis in patients with chronic heart failure (CHF), but little is known about the relationship between SDB and life-threatening arrhythmias. METHODS AND RESULTS: Fifty patients with CHF and SDB (33 male; mean age, 61 years) underwent Holter electrocardiogram and portable sleep monitoring simultaneously. The circadian variation in positive T-wave alternans (TWA; >65 µV) was determined during 6-h intervals (0-6, 6-12, 12-18, and 18-24 h). In addition, power spectral analysis of heart rate variability (HRV) was evaluated across a 24-h period. The subjects were divided into 2 groups based on whether respiratory disturbance index was ≥20 events/h (Group A, n=24) or not (Group B, n=26). The prevalence of positive TWA, parameters in HRV and the occurrence of ventricular tachycardia (>5 beats) were compared between the 2 groups. The prevalence of positive TWA in Group A was significantly higher than that in Group B in all 6-h intervals. Low-frequency and high-frequency powers of HRV were significantly lower in Group A than in Group B across a 24-h period. Importantly, the prevalence of ventricular tachycardia was significantly higher in Group A than in Group B (46% vs. 19%, P=0.04). CONCLUSIONS: SDB may induce cardiac electrical instability associated with life-threatening arrhythmias across a 24-h period in CHF.

Left ventricular plasty improved cardiac function in a case of takotsubo cardiomyopathy with persistent aneurysm.

A 72-year-old woman was admitted to a local hospital due to repeated chest pain in December 2011. On admission, blood tests showed elevation of cardiac enzyme and B-type natriuretic peptide levels. Electrocardiography showed ST-segment elevation in almost all leads. Echocardiography showed akinesis in left ventricular (LV) apex, and hyperkinesis in basal LV. Urgent cardiac catheterization was performed. Coronary angiography showed no significant organic stenosis and the acetylcholine provocation test did not evoke coronary spasm. The left ventriculography revealed marked akinesis of the apical ballooning with hyperkinesis of the basal LV segments, suggesting takotsubo cardiomyopathy. Following the diagnosis, she started treatment for LV dysfunction with standard pharmacotherapy including beta blocker, aldosterone receptor blocker, and angiotensin-converting enzyme inhibitor. Even after 3 months, echocardiography demonstrated that LV wall motion was not recovered, and her symptoms of heart failure were not improved. Based on these findings, we considered that surgical LV plasty was necessary for the treatment of cardiac dysfunction in this patient. She underwent surgical operation (aneurysma resection and LV volume reduction) in April 2011. Pathological examination of the excised myocardial tissue from the aneurysm revealed damaged cardiomyocytes replaced with interstitial fibrosis and adipose tissue. After surgery, her LV systolic function and clinical symptoms dramatically improved. .

Uric acid increases the incidence of ventricular arrhythmia in patients with left ventricular hypertrophy.

BACKGROUNDS: Elevated uric acid (UA) level is reported to be related to the development of left ventricular hypertrophy (LVH) which is associated with high incidence of ventricular tachycardia (VT) and sudden cardiac death. However, little is known about the association between serum UA levels and the occurrence of VT. Thus, we examined the relationship between serum UA levels and the appearance of VT in patients with LVH. METHODS: The study subjects consisted of 167 patients (110 males, mean age 67.4 ± 12.7 years) with LVH detected by echocardiography. These patients were divided into two groups based on whether VT was presented (defined by more than 5 beats, n = 27) or not (n = 140) by 24-hour Holter ECG monitoring. Left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVDd), the E/A ratio and deceleration time of transmitral flow velocity were assessed by echocardiography in each group. In addition, blood urea nitrogen (BUN), creatinine, estimated glomerular filtration rate (eGFR), sodium, potassium, hemoglobin, total bilirubin and UA were compared in each group. RESULTS: Echocardiographic findings did not show the difference between the two groups. However, BUN and UA levels in the VT group were significantly higher than those in the Non-VT group (p < 0.01). eGFR was significantly lower in the VT group than that in the Non-VT group (p < 0.01). A multivariate logistic regression analysis identified the UA level as an independent predictive factor for the occurrence of VT (odds ratio 1.61, 95% confidence interval 1.1-2.2, p < 0.01). CONCLUSIONS: These results suggest that serum UA level is a useful marker for predicting ventricular arrhythmias in patients with LVH.

High sensitivity C-reactive protein predicts nonresponders and cardiac deaths in severe heart failure patients after CRT implantation.

The purpose of this study was to determine whether high sensitivity C-reactive protein (hsCRP) before cardiac re-synchronization therapy (CRT) implantation was able to predict the response to CRT and cardiac deaths in severe heart failure patients. The study population consisted of 65 heart failure patients (46 males, mean age 65.0 ± 11.8 years, NYHA class III/IV) with CRT implantation. Levels of hsCRP and B-type natriuretic peptide (BNP) were measured before CRT implantation. Left ventricular end-diastolic volume index (LVEDVI), left ventricular end-systolic volume index (LVESVI), and left ventricular ejection fraction (LVEF) were assessed by echocardiography at the same time. At 6 months after device implantation follow-up, echocardiography was performed and reverse remodeling was defined as > 15% reduction in LVESV. Of the 61 patients (4 patients died within 6 months), 41 patients (67%) and 20 patients (33%) were classified as responders (group-R) and nonresponders (group-NR), respectively. Cardiac deaths occurred more frequently in group-NR than in group-R (29% versus 5%, P < 0.05). Hs-CRP level was significantly higher in group-NR than in group-R (P < 0.01). Multivariate logistic regression analysis showed an independent relationship between hsCRP and the incidence of nonresponders (odds ratio: 1.499, P = 0.011). Stepwise multivariate Cox proportional hazard analysis identified the hsCRP level as the strongest predictive factor for cardiac death (hazard ratio: 1.337, P = 0.001). Receiver operating characteristic (ROC) analysis revealed hsCRP levels of 3.0 mg/L as the cut-off value for cardiac mortality. The hsCRP level may provide a new insight into CRT implantation for severe heart failure by predicting responses to CRT and cardiac death.

Intrathoracic impedance changes reflect reverse left ventricular remodeling in response to cardiac resynchronization therapy in chronic heart failure patients.

Intrathoracic impedance monitoring has been reported to be useful for prediction of worsening chronic heart failure (CHF). However, it has not revealed the relation between changes in intrathoracic impedance and improvement of cardiac function in CHF patients with cardiac resynchronization therapy (CRT) implantation. Therefore, we investigated whether intrathoracic impedance change reflects reverse left ventricular (LV) remodeling in response to CRT in patients with CHF. The study subjects consisted of 29 CHF patients (23 males, mean age 64 ± 12 years) with CRT-defibrillator (CRT-D) implantation. The patients were divided into two groups based on whether the Opti-vol Fluid Index® reached over 60 ohms (group A, n = 7) or not (group B, n = 22) within 6 months of observation after CRT-D implantation. Levels of plasma B-type natriuretic peptide (BNP) were measured, and LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and LV ejection fraction (LVEF) were evaluated before and 6 months after CRT-D implantation. In group B, BNP (556 ± 88 pg/mL versus 330 ± 70 pg/mL, P < 0.05), LVEDV (177 ± 18 mL versus 149 ± 14 mL, P < 0.01), and LVESV (128 ± 14 mL versus 100 ± 12 mL, P < 0.01) were significantly decreased 6 months after CRT-D implantation. LVEF (28 ± 2% versus 35 ± 2%, P < 0.01) was significantly increased after CRT-D implantation. On the other hand, no significant changes were detected in any parameters in group A. These data showed intrathoracic impedance changes reflected reverse LV remodeling in response to CRT in patients with CHF. Therefore, the monitoring of changes in intrathoracic impedance is useful for predicting CRT responders in patients with CHF.

Adaptive servo ventilation improves Cheyne-Stokes respiration, cardiac function, and prognosis in chronic heart failure patients with cardiac resynchronization therapy.

BACKGROUND: Cheyne-Stokes respiration (CSR-CSA) is often observed in patients with chronic heart failure (CHF). Although cardiac resynchronization therapy (CRT) is effective for CHF patients with left ventricular dyssynchrony, it is still unclear whether adaptive servo ventilation (ASV) improves cardiac function and prognosis of CHF patients with CSR-CSA after CRT. METHODS AND RESULTS: Twenty two patients with CHF and CSR-CSA after CRT defibrillator (CRTD) implantation were enrolled in the present study and randomly assigned into two groups: 11 patients treated with ASV (ASV group) and 11 patients treated without ASV (non-ASV group). Measurement of plasma B-type natriuretic peptide (BNP) levels (before 3, and 6 months later) and echocardiography (before and 6 months) were performed in each group. Patients were followed up to register cardiac events (cardiac death and re-hospitalization) after discharge. In the ASV group, indices for apnea-hypopnea, central apnea, and oxyhemoglobin saturation were improved on ASV. BNP levels, cardiac systolic and diastolic function were improved with ASV treatment for 6 months. Importantly, the event-free rate was significantly higher in the ASV group than in the non-ASV group. CONCLUSIONS: ASV improves CSR-CSA, cardiac function, and prognosis in CHF patients with CRTD. Patients with CSR-CSA and post CRTD implantation would get benefits by treatment with ASV.

Attenuation of diastolic heart failure and life-threatening ventricular tachyarrhythmia after peripheral blood stem cell transplantation combined with cardioverter-defibrillator implantation in myeloma-associated cardiac amyloidosis.

A patient had multiple myeloma and associated cardiac amyloidosis, which caused diastolic dysfunction and recurrent ventricular fibrillation. After implantation of a cardioverter-defibrillator (ICD), the patient underwent autologous peripheral blood stem cell transplantation (PBSCT). The life-threatening arrhythmias, such as ventricular fibrillation, disappeared, and diastolic dysfunction assessed by quantitative gated single photon emission computed tomography and Doppler echocardiography improved 7 months later. This may be the first report to document improvement of both a lethal rhythm disorder and diastolic dysfunction by PBSCT following ICD implantation in a case of cardiac amyloidosis associated with multiple myeloma.

Synergetic antioxidant and vasodilatory action of carbon monoxide in angiotensin II - induced cardiac hypertrophy.

The aim of this study was to determine the effects of carbon monoxide (CO) at a nontoxic low concentration on the cardiac and vascular hypertrophic response and reactive oxygen species generation, compared with the action of a vasodilator, hydralazine. Twelve- to 16-week-old low-density lipoprotein receptor knockout mice were subjected to angiotensin II (Ang II) infusion using osmotic minipumps (Ang II group; n=11) for 2 weeks. Controls were administered saline (n=10). Animals were exposed to CO in a chamber at 60 ppm for 2 hours per day with or without Ang II infusion (Ang II+CO group, n=10; CO group, n=9). Hydralazine was administered with Ang II infusion (n=10). Animals exhibited elevated arterial carboxyhemoglobin after CO exposure. Although the CO exposure did not affect systolic blood pressure without Ang II infusion, the hypertensive response after Ang II infusion was significantly attenuated by CO. Accordingly, the mice in the Ang II+CO group showed lesser left ventricular hypertrophy compared with those in the Ang II group. CO treatment also attenuated aortic hypertrophy. Interestingly, these changes were accompanied by the reduction of reactive oxygen species production, p47(phox) and p67(phox) subunit expressions of reduced nicotinamide-adenine dinucleotide phosphate oxidase, and Akt phosphorylation. Although hydralazine showed stronger antihypertensive action, superior inhibition on cardiac hypertrophy was obtained by CO (P<0.05). Furthermore, Ang II-dependent myocardial reactive oxygen species generation was more effectively suppressed by CO. Low-dose exogenous CO treatment attenuates Ang II-dependent reactive oxygen species generation, suggesting that appropriate CO administration alleviates hypertension and reduces organ hypertrophy mediated by Ang II.