Fatal Arrhythmic Risks in Cardiac Sarcoidosis With Mildly Impaired Cardiac Function.

Background: The prognosis and later fatal arrhythmia in cardiac sarcoidosis (CS) with relatively preserved cardiac function were unclear. Objectives: This study aimed to evaluate the prognosis and arrhythmic events in patients with CS and mildly impaired cardiac function. Methods: Data were collected from a nationwide Japanese cohort survey conducted in 57 hospitals (n = 420); 322 patients with CS with left ventricular ejection fraction (LVEF) >35% were investigated. Results: Ventricular tachycardia (VT) manifestation was present in 50 patients (16%) and absent in 272 (84%), of whom 36 (72%) and 46 (17%), respectively, had an implantable cardioverter-defibrillator (ICD). Over a median of 5 years, 23 all-cause deaths and 31 appropriate ICD discharges were observed. In Kaplan-Meier analysis, all-cause death did not differ between patients with and without VT manifestation (P = 0.660), although appropriate ICD therapy was significantly less used in patients without VT manifestation than in those with VT manifestation (P < 0.001). Of the 272 patients without VT manifestation, 18 had ventricular arrhythmic events (VAEs), including 3 sudden cardiac deaths and 15 appropriate ICD discharges. In multivariate analysis, concomitant nonsustained ventricular tachycardia (NSVT) with atrioventricular block (AVB), lower LVEF, abnormal gallium-67 scintigraphy or 18F-fluorodeoxyglucose positron emission tomography of the heart (Ga/PET), and concomitant NSVT with abnormal Ga/PET at CS diagnosis were independent predictors of VAEs (P = 0.008, P = 0.021, P = 0.049, and P = 0.024, respectively). Conclusions: If concomitant NSVT with AVB, concomitant NSVT with abnormal Ga/PET, or abnormal Ga/PET is observed in patients with CS and mildly impaired cardiac function (LVEF >35%), ICD should be considered as primary prevention.

Conduction System Pacing Upgrade in Chronic Heart Failure with Severe Left Ventricular Dysfunction and Chronic Atrial Fibrillation.

Cardiac resynchronization therapy (CRT) is a standard treatment for patients with severe congestive heart failure. However, one-third of patients receiving CRT are non-responders. Conduction system pacing (CSP), including His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP), has become an alternative to CRT therapy. Furthermore, CRT therapy with CSP has shown to be more effective than CRT alone. When an implantable cardiac defibrillator or CRT-defibrillator is implanted with CSP, the problem of which port the HBP lead and LBBAP lead should be connected to arises. We report 2 cases of upgrading to CRT with CSP by utilizing the atrial ports for HBP and LBBAP leads. The procedure is a simple, reasonable, and effective therapy for end-stage heart failure.

Giant aneurysm of left circumflex artery branch with fistula to the coronary sinus: a case report.

BACKGROUND: Aneurysm of a coronary artery branch with a fistula is extremely rare. Here, we present a case of giant aneurysm of the left circumflex artery branch with a fistula to the coronary sinus treated successfully with aneurysmectomy. CASE PRESENTATION: A 58-year-old woman was referred to our hospital due to an abnormal pericardial mass found by multidetector computed tomography. Imaging examination revealed a dilated left circumflex artery branch with a 30-mm aneurysm. Coronary angiography confirmed a left circumflex artery branch aneurysm with a fistula to the coronary sinus. As percutaneous occlusion of the aneurysm by catheterization was considered unsuccessful, the aneurysm was resected, and the fistula was occluded surgically with excellent outcome. Pathological examination suggested that congenital factors may have contributed to the development of the aneurysm. Computed tomography showed no recurrence of the aneurysm at 1-year postoperative follow-up. CONCLUSIONS: We presented a case of giant aneurysm of the left circumflex artery branch with a fistula to the coronary sinus. This is the first report of the combination of a giant coronary artery branch aneurysm with a fistula to the coronary sinus. Surgical aneurysmectomy should be considered in such cases to avoid fatal aneurysmal complications.

The necessity of routine screening for deep vein thrombosis before surgery.

Background: Pulmonary embolism (PE) from deep venous thrombosis (DVT) can be a fatal postoperative complication. Preventive measures for venous thromboembolism (VTE) was evaluated in this hospital. Materials and methods: Preoperative DVT screening following surgery under general anesthesia in 2009-2016 was examined, and then, 217 patients diagnosed with DVT by preoperative leg-ultrasound (US) between 2014 and 2016 were retrospectively analyzed. Results: There were 24,826 operations under general anesthesia in the study period. Preoperative leg-US was performed in 5345 (21.5%) patients, and 648 (12.1% of patients, 2.6% of total operations) were diagnosed with DVT. In 2014-2016, 217 patients, which is 11.7% of patients undergoing leg-US, were diagnosed with DVT. DVT was found in the proximal veins (upper popliteal vein) in 86 (39.6%) patients. A total of 143 (62%) patients were considered to have organized thrombi, no patient developed pulmonary embolism, and 133 (58%) patients were discharged without follow-up examination for DVT. Ninety-six patients were evaluated for changes on leg-US, with no difference in the results with and without anticoagulant use. On multivariate logistic regression analysis, anticoagulants appeared effective for non-organized thrombi, higher D-dimer levels (≥10 µg/mL), or orthopedic surgery. Conclusion: Preoperative screening for DVT did not appear useful, and treatment of asymptomatic DVT was not always necessary.

The characteristics of Japanese guidelines on diagnosis and treatment of cardiac sarcoidosis compared with the previous guidelines.

Sarcoidosis in Japanese sarcoidosis is characterized by a high prevalence of cardiac involvement. In this regard, cardiac sarcoidosis (CS) continues to be an important focus of study among physicians caring for sarcoidosis in Japan. The Japanese Ministry of Health, Labor and Welfare (MHLW) and Japan Society of Sarcoidosis and other Granulomatous Disorders (JSSOG) have published clinical guidelines aiming to assist clinical practices. Recently, the Japanese Circulation Society (JCS) has published new clinical guidelines for the diagnosis and treatment of CS that contain several new insights compared to previously published guidelines in Japan and other countries.

Successful Treatment of Refractory Cardiogenic Shock and Electrical Storm Using the IMPELLA 5.0 with Atrial Overdrive Pacing, in a Patient with Severe Peripheral Arterial Disease.

Cardiogenic shock with electrical storm is a challenging condition to manage in patients with acute myocardial infarction despite primary percutaneous coronary interventions. While active mechanical circulatory support devices may improve hemodynamics in this situation, identifying the appropriate arterial access for device deployment is difficult in patients with severe peripheral arterial disease due to severe stenosis or obstruction and tortuous path of the femoral-iliac artery or descending aorta; additionally, this also reduces the mechanical viability of the implanted circulatory support devices, thus posing a risk for limb ischemia. Herein, we report on the effectiveness of the IMPELLA 5.0, deployed via the axillary artery, in combination with atrial overdrive pacing to manage a patient with cardiogenic shock and electrical storm, without extracorporeal membrane oxygenation. Our strategy, which does not require access via the groin area, may be an attractive option for patients with severe peripheral arterial disease, particularly those with aorto-iliac occlusive disease.

Prognosis and Outcomes of Clinically Diagnosed Cardiac Sarcoidosis Without Positive Endomyocardial Biopsy Findings.

Background: Diagnosis of cardiac sarcoidosis (CS) is sometimes difficult due to a low positive rate of epithelioid granulomas by endomyocardial biopsy (EMB). Accordingly, Japanese guidelines can allow the CS diagnosis using clinical data alone without EMB results (clinical CS) since 2006. However, little is known about prognosis and outcome of clinical CS. Objectives: Purpose of this study was to analyze the prognosis, outcomes, and response to corticosteroid of clinical CS using large-scale cohort survey. Methods: Overall, 422 CS patients (mean age 60 ± 13 years, 68% female, median follow-up period of 5 years), including 345 clinical CS and 77 EMB-positive patients, histologically diagnosed CS (histological CS) by Japanese guidelines, were enrolled and examined. Results: Clinical profile (age, sex, initial cardiac arrhythmias, and abnormal uptake of gallium-67 scintigraphy or 18F-fluorodeoxyglucose positron emission tomography in heart) was similar in both groups. Although clinical CS had better prognosis (P = 0.018) and outcome (all-cause death, appropriate defibrillator therapy, and heart transplantation; P = 0.008), multivariate Cox hazard analysis revealed that left ventricular ejection fraction (LVEF) and sustained ventricular tachycardia history were independently associated with outcome (P < 0.001 and P = 0.002, respectively), but not with the diagnosed CS category. Moreover, similar LVEF recovery after corticosteroid was observed in both groups with low LVEF (≤35%) at the 1-year follow-up period (P < 0.001). Conclusions: In clinical CS according to the Japanese guideline, prophylactic implantable-cardioverter-defibrillator and immunosuppressive therapy are important in patients with low LVEF or ventricular tachycardia history, similar to histological CS.

Japanese Antibacterial Drug Management for Cardiac Sarcoidosis (J-ACNES): A multicenter, open-label, randomized, controlled study.

BACKGROUND: Cardiac sarcoidosis (CS) is a noncaseating granulomatous disease of unknown etiology. Lifelong immunosuppressive therapy, most frequently using corticosteroids, is a standard therapy to control hypersensitivity of immune reactions and prevent inflammation. However, it sometimes causes various systemic adverse effects and requires dose escalation. Thus, additional therapy may be required for the treatment of this disease. Recently, Propionibacterium acnes (P. acnes) was reported as one of the etiologic agents of CS, indicating that antibacterial drugs (ABD) may be effective for the treatment of CS. The objective of this study was to investigate the effect of ABD treatment, in addition to standard corticosteroid therapy, in patients with CS. METHODS: The Japanese Antibacterial Drug Management for Cardiac Sarcoidosis (J-ACNES) trial was designed as a prospective, multicenter, randomized, open-label, controlled clinical trial. The patients will be randomized to receive either standard corticosteroid therapy plus ABD therapy (ABD group) or standard corticosteroid therapy (standard group). The primary endpoint is change in the total standardized uptake value at 6 months vs baseline using fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography. Secondary endpoints include efficacy, prognosis, and safety. RESULTS: The results of this study are currently under investigation. CONCLUSION: The J-ACNES trial will be the first prospective study assessing the clinical benefit and safety of ABD therapy, in addition to corticosteroid treatment, in patients with CS. Our findings may improve treatment of patients with CS, as additional ABD therapy reduces recurrence of inflammation and elucidates the mechanism of sarcoidosis.

Utilization of Flavonoid Compounds from Bark and Wood. III. Application in Health Foods.

Dietary supplements ACAPOLIA® and ACAPOLIA PLUS have been sold in Japan under the classification "Foods in General" for a number of years. In April 2015, the classification of "Foods with Function Claims" was introduced in Japan to make more products available to the public that were clearly labeled with functional claims based on scientific evidence. In order to obtain recognition of ACAPOLIA PLUS under this new classification, the following information needed to be established. The safety of the bark extract of Acacia mearnsii was shown from the history of the long-term safe consumption of the extract as a health supplement, together with several additional clinical safety tests. Robinetinidol-(4α,8)-catechin was detected by high performance liquid chromatography (HPLC) in the supplement and was suitable for use as the basis of the quantitative analysis. In clinical tests, the amount of change in the plasma glucose concentration in the initial 60 min after rice consumption by a test group who had been given the Acadia extract was significantly lower than the glucose concentration in the group that was given a placebo. The blood glucose incremental areas under the curve (IAUC) in the first 60 min after rice consumption were also significantly lower in the Acacia group. The functional mechanisms were explained in terms of the inhibition of the absorption of glucose in the small intestine and the reduction in the activity of the digestive enzymes caused by proanthocyanidins derived from A. mearnsii bark. As a result, ACAPOLIA PLUS was accepted as a "Food with Function Claims" in August 2016. ACAPOLIA PLUS is now sold under this new classification. The growth of a typical intestinal bacterium is inhibited by an extract containing flavonoid compounds from A. mearnsii bark; thus, one of the future directions of study must be a comprehensive investigation of the effect that flavonoid compounds, proanthocyanidins, have on intestinal bacteria.

Tannins from Acacia mearnsii De Wild. Bark: Tannin Determination and Biological Activities.

The bark of Acacia mearnsii De Wild. (black wattle) contains significant amounts of water-soluble components acalled "wattle tannin". Following the discovery of its strong antioxidant activity, a wattle tannin dietary supplement has been developed and as part of developing new dietary supplements, a literature search was conducted using the SciFinder data base for "Acacia species and their biological activities". An analysis of the references found indicated that the name of Acacia nilotica had been changed to Vachellia nilotica, even though the name of the genus Acacia originated from its original name. This review briefly describes why and how the name of A. nilotica changed. Tannin has been analyzed using the Stiasny method when the tannin is used to make adhesives and the hide-powder method is used when the tannin is to be used for leather tanning. A simple UV method is also able to be used to estimate the values for both adhesives and leather tanning applications. The tannin content in bark can also be estimated using NIR and NMR. Tannin content estimations using pyrolysis/GC, electrospray mass spectrometry and quantitative 31P-NMR analyses have also been described. Tannins consists mostly of polyflavanoids and all the compounds isolated have been updated. Antioxidant activities of the tannin relating to anti-tumor properties, the viability of human neuroblastoma SH-SY5Y cells and also anti-hypertensive effects have been studied. The antioxidant activity of proanthocyanidins was found to be higher than that of flavan-3-ol monomers. A total of fourteen papers and two patents reported the antimicrobial activities of wattle tannin. Bacteria were more susceptible to the tannins than the fungal strains tested. Several bacteria were inhibited by the extract from A. mearnsii bark. The growth inhibition mechanisms of E. coli were investigated. An interaction between extracts from A. mearnsii bark and antibiotics has also been studied. The extracts from A. mearnsii bark inhibit the growth of cyanobacteria. Wattle tannin has the ability to inactivate α-amylase, lipase and glucosidase. In vivo experiments on anti-obesity and anti-diabetes were also reported. Several patents relating to these enzymes for anti-diabetes and anti-obesity are in the literature. In addition, studies on Acacia bark extract regarding its antitermite activities, inhibition of itching in atopic dermatitis and anti-inflammatory effects have also been reported. The growth of bacteria was inhibited by the extract from A. mearnsii bark, and typical intestinal bacteria such as E. coli, K. pneumoniae, P. vulgaris and S. marcescenes was also inhibited in vitro by extracts. Based on these results, the Acacia bark extract may inhibit not only the growth of these typical intestinal bacteria but also the growth of other types of intestinal bacteria such as Clostridium and Bacteroides, a so-called "bad bacteria". If the tannin extract from A. mearnsii bark inhibits growth of these "bad bacteria" in vivo evaluation, the extracts might be usable as a new dietary supplement, which could control the human intestinal microbiome to keep the body healthy.

[Hybrid Coronary Revascularization of Minimally Invasive Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in a Patient with Left Main Coronary Stenosis].

We report a successful case of hybrid coronary revascularization of minimally invasive coronary artery bypass grafting( MICS-CABG) and percutaneous coronary intervention(PCI). The patient was a 78-year-old man with angina pectoris due to left main trunk (LMT) lesion, and had a history of repeated PCI to the left anterior descending artery (LAD) and the left circumflex artery (LCX) for angina pectoris. He presented with a chest pain on effort in June, 2015. A coronary angiogram showed a severe stenosis in the LMT extending to LAD and LCX. We performed hybrid therapy of CABG to LAD, and PCI to LMT and the proximal portion of LCX because the lesion was technically and suitable for PCI. CABG to LAD was performed via left mini thoracotomy using the left inter mammary artery (LIMA). LIMA was harvested under 3-dimentional endoscope. On the 5th post-operative day, PCI was performed to LMT and LCX. The postoperative course was uneventful and he was discharged on the 11th post-operative day. This case suggests that hybrid coronary revascularization is less invasive and feasible for selected patients with multi-vessel disease.

Interferon Therapy Exacerbated Pulmonary Hypertension in a Patient with Hepatitis C Virus Infection: Pathogenic Interplay among Multiple Risk Factors.

Pulmonary arterial hypertension (PAH) is known to develop as a consequence of multiple genetic and/or non-genetic factors. A 27-year-old woman with chronic hepatitis C virus (HCV) infection developed severe PAH after interferon (IFN) therapy. Although most of the reported clinical courses of IFN-induced PAH are poor despite the discontinuation of IFN, the present patient was successfully treated with a triple combination therapy. In this report, we discuss the crosstalk among chronic HCV infection, IFN therapy, autoimmune disorders, and portal hypertension in the pathogenesis and development of PAH.

Failure of steroid withdrawal guided by 18F-FDG PET in a patient with cardiac sarcoidosis.

A 71-year-old man diagnosed with cardiac sarcoidosis (CS) 11 years previously underwent implantation of an implantable cardioverter defibrillator due to sustained ventricular tachycardia. Over past decade, his condition of CS did not progress on the maintenance steroid dose of 7.5 mg per day. We attempted to taper and discontinue steroids according to the results of fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET). On the basis of the results, we reduced the oral steroid dose slowly. In spite of no abnormal 18F-FDG uptake in the myocardium, advanced atrioventricular conduction block and deterioration of the ventricular pacing threshold occurred during the course of steroid withdrawal. Plasma brain natriuretic peptide (BNP) increased from 94 to 842 pg/ml. It was necessary to add new ventricular and atrial leads to synchronize atrial and ventricular contractions, and the pacing mode for bradycardia was changed to dual-chamber DDD-60 ppm. Fatigue disappeared, and BNP levels decreased to 147 pg/ml. 18F-FDG PET might have a limit to detect small scattered inflammatory foci. This case highlights the need for caution when reducing steroid doses in CS patients, guided by 18F-FDG PET only. .

Diagnostic advantage of stress computed tomography myocardial perfusion over single-photon emission computed tomography for the assessment of myocardial ischemia.

BACKGROUND: This study compared adenosine stress computed tomography myocardial perfusion (CTP) with single-photon emission computed tomography (SPECT) in the diagnosis of functionally significant coronary artery stenosis using fractional flow reserve (FFR) as reference standard. METHODS: We included a total of 93 coronary arteries from 31 patients in whom at least one vessel with ≥50% stenosis was detected with computed tomography coronary angiography. All patients underwent both SPECT and adenosine stress CTP, followed by invasive coronary angiography (ICA) and FFR. Diagnostic accuracy between CTP and SPECT was compared according to positive findings of either ≥99% stenosis on ICA or FFR ≤0.8. RESULTS: Among 78 vessels eligible for the quantitative analyses, significant coronary artery disease (CAD) was diagnosed in 22 vessels of 19 patients. Comparison of CTP vs. SPECT for sensitivity, specificity, positive predictive value (PPV), negative predictive value, and accuracy in detecting significant CAD were 59% vs. 18%, 96% vs. 93%, 87% vs. 50%, 86% vs. 74%, and 86% vs. 72%, respectively. CONCLUSIONS: CTP demonstrated a significant diagnostic advantage over SPECT in the identification of significant CAD, especially in terms of sensitivity and PPV. Adenosine stress CTP is useful for the noninvasive diagnosis of functionally significant CAD.

Importance of cystatin C and uric acid levels in the association of cardiometabolic risk factors in Japanese junior high school students.

BACKGROUND: Serum cystatin C (CysC), a novel marker of renal function, is associated with the components of metabolic syndrome in adults. Little is known about the utility of CysC and its association with cardiometabolic risks in young subjects. METHODS AND RESULTS: In a cohort of 454 Japanese junior high school students, the distribution of serum CysC levels and associated variables were analyzed. CysC levels were significantly higher in boys than in girls (0.92±0.10mg/L vs. 0.77±0.08mg/L, p<0.001). CysC was significantly correlated with serum creatinine (r=0.473, p<0.001), and serum uric acid (SUA) (r=0.546, p<0.001). Multivariable regression analysis revealed significant associations between CysC and SUA in all subjects (ß=0.241, p<0.001), and in boys and girls separately (ß=0.264 and 0.240, respectively, both p<0.001). Importantly, subjects with elevation of both serum CysC and SUA levels had the highest ratio of triglyceride to high-density lipoprotein cholesterol. CONCLUSIONS: CysC had significant associations with both creatinine and SUA in Japanese junior high school students. The concomitant elevation of serum CysC and SUA levels was associated with subclinical lipid metabolism dysregulation, and suggested the presence of cardiometabolic risk accumulation.