Impact of Implementation of a Region-Wide Low-Density Lipoprotein Cholesterol Management Clinical Pathway for the Secondary Prevention of Acute Myocardial Infarction.

BACKGROUND: Aggressive lipid-lowering therapy is important for secondary prevention of acute myocardial infarction (AMI). The recommended target for low-density lipoprotein cholesterol (LDL-C) of <70 mg/dL is often not achieved. To address this gap, we implemented a clinical pathway in all hospitals that perform percutaneous coronary interventions (PCI) with primary care physicians in Nagasaki and aimed to validate the effectiveness of this pathway in an acute setting. METHODS AND RESULTS: This retrospective cohort study included medical records extracted from 8 hospitals in Nagasaki, Japan, where PCI was performed for patients with AMI. The index date was defined as the date of hospitalization for AMI between July 1, 2021, and February 28, 2023. The primary outcome was the rate of achieving LDL-C <70 mg/dL at discharge. The median baseline LDL-C level at admission was 121 mg/dL (n=226) in the pre-implementation group and 116 mg/dL (n=163) in the post-implementation group. In the post-implementation group, 131 patients were treated using the clinical pathway. The rate of achieving LDL-C <70 mg/dL at discharge increased significantly from 37.2% before implementation to 54.6% after implementation. Logistic regression analysis revealed a positive correlation between the implementation of the clinical pathway and achieving LDL-C <70 mg/dL. CONCLUSIONS: Implementation of a region-wide clinical pathway for LDL-C management significantly improved the rate of intensive lipid-lowering therapy and the achievement of LDL-C targets.

Impact of tolvaptan on improvement of tricuspid regurgitation and right ventricular dimension in patients with right-sided heart failure.

Managing right-sided chronic heart failure (CHF) due to tricuspid regurgitation (TR) remains a clinical challenge. Tolvaptan (TLV), a vasopressin V2 receptor inhibitor, is effective in controlling decompensated HF. However, its effects on right-sided CHF caused by TR are unclear. We sought to clarify the effects of TLV in CHF patients complicated with TR. The cohort consisted of 33 CHF patients with moderate or severe TR and permanent atrial fibrillation, who required hospitalization for HF. We observed 19 patients treated with TLV plus conventional therapies (TLV group) and 14 patients with conventional therapies alone (conventional group). Clinical characteristics, echocardiographic parameters, and laboratory data were investigated. Baseline characteristics were similar between groups. In the TLV group, the severity of TR at admission was 73.7% moderate and 26.3% severe. In the conventional group, these percentages were 85.7% and 14.3%, respectively. During the follow-up, the severity of TR improved in the TLV group (trivial-mild: 52.6%; moderate: 36.8%; severe: 10.5%) (p < 0.01). However, it did not improve in the conventional group (trivial-mild: 21.4%; moderate: 50.0%; severe: 28.6%) (p = 0.08). The diameter of the tricuspid annulus (p < 0.01), basal (p = 0.02), and mid right ventricle (p = 0.04) was reduced at follow-up in the TLV group. Nevertheless, these parameters did not change in the conventional group. Serum creatinine levels were maintained (p = 0.74) in the TLV group, but deteriorated in the conventional group (p = 0.03). TLV reduced right ventricular dimensions and improved TR without deterioration of renal function. Thus, TLV may be a new drug for the treatment of CHF patients with TR.

Optimizing self-expandable transcatheter heart valve sizing in patients with small sinus of Valsalva.

OBJECTIVES: To evaluate the feasibility and efficacy of transcatheter aortic valve replacement (TAVR) in patients with small sinus of Valsalva (SOV). BACKGROUND: Patients with small SOV are considered unfavorable for TAVR since it carries risk of coronary obstruction after valve implantation. Therefore, these patients with small SOV were excluded from previous clinical trials. METHODS: Between February 2017 and February 2019, a total of 139 consecutive patients with severe aortic stenosis (AS) undergoing TAVR were prospectively enrolled in the Tokai Valve Registry. Patients with small SOV who were treated with smaller size of self-expandable transcatheter heart valve (THV) than expected by perimeter-based sizing were included in this study. Eleven patients (7.9%) were included. RESULTS: Mean age was 86.5 ± 3.8 years and median STS Score was 8.5% (interquartile range: 6.3-12.3%). Device success was accomplished in all patients and no coronary obstruction was observed. No moderate/severe paravalvular leakage, new onset conduction disturbance, and new permanent pacemaker implantation were noted. At 30-day follow-up, mean aortic valve gradient was 6.9 ± 1.7 mmHg and mean indexed aortic valve area was 0.95 ± 0.16 cm2 /m2 . Prosthetic valve performance was stable at 12-month follow-up. No severe prosthesis patient mismatch was documented at any time point. No in-hospital, 30-day, and 12-month mortality were observed. The median follow-up was 711 days (IQR: 547-803 days), and no patient was lost to follow-up. CONCLUSIONS: Our preliminary experience suggests favorable safety and efficacy of TAVR utilizing self-expandable THV with intentional down-sizing in patients with severe AS and small SOV in a mid-term follow-up.

Lipid profile and risk factors for neoatherosclerosis after drug-eluting stent implantation in acute coronary syndrome.

BACKGROUND: Predictors of neoatherosclerosis in patients who received primary percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) remain unclear. OBJECTIVE: The aim of this study is to investigate the frequency and risk factors of neoatherosclerosis 1-year after the onset of ACS. METHODS: This study investigated 83 patients who underwent PCI for ACS followed by 1-year follow-up optical coherence tomography. The patients were categorized into the neoatherosclerosis (n = 11) and non-neoatherosclerosis groups (n = 72). Baseline characteristics, PCI procedures, medical therapies, and blood tests at 1-year, including detailed lipid profiles, were compared between the two groups. RESULTS: Diabetes mellitus was more prominent in the neoatherosclerosis than in the non-neoatherosclerosis group (45% vs. 17 %, respectively, p = 0.03). Total cholesterol (171 ± 37 mg/dL vs. 145 ± 25 mg/dL, respectively, p < 0.01), non-high-density lipoprotein cholesterol (HDL-C) (124 ± 36 mg/dL vs. 94 ± 24 mg/dL, respectively, p < 0.01), low-density lipoprotein cholesterol (94 ± 36 mg/dL vs. 72 ± 19 mg/dL, respectively, p < 0.01), and lipoprotein (a) (Lp[a]) (70 [19-112] mg/dL vs. 10 [3-25] mg/dL, respectively, p = 0.03) at follow-up were significantly higher in the neoatherosclerosis group. Multivariate analysis revealed that neoatherosclerosis was associated with high serum non-HDL-C (odds ratio [OR]: 1.075; 95 % confidence interval [CI]: 1.011-1.144; p < 0.01) and high serum Lp(a) levels (>30 mg/dL) (OR: 11.0; 95 % CI: 1.492-81.02; p = 0.02). CONCLUSION: Poorly controlled non-HDL-C and Lp(a) would be risk factors of neoatherosclerosis in patients 1-year after ACS.

Feasibility and Outcome of Transjugular Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement.

Background: There are limited data on the impact of intracardiac echocardiography (ICE)-guided transcatheter aortic valve replacement (TAVR) on the new permanent pacemaker implantation (PPMI) rate. Objectives: This study investigated the feasibility and outcome of transjugular ICE (TJ-ICE) -guided TAVR, by visualizing the relationship between the membranous septum (MS) and the transcatheter aortic valve (TAV). Methods: Among patients with severe aortic stenosis who underwent TAVR between February 2017 and June 2020, this study enrolled a total of 163 patients with TJ-ICE-guided TAVR. MS length was measured by ICE. The primary endpoint of this study was the incidence of new PPMI at 30 days. Results: The mean age of the patients in this study was 84.9 ± 4.6 years, and 71.2% of the patients were female. Device success was 96.3% with TJ-ICE guidance. A TJ-ICE-related complication occurred in 1 case (0.6%). The median length of the MS was 5.8 mm (IQR: 5.0-6.9 mm). Excellent intraobserver (intraclass correlation coefficient [ICC]: 0.94; 95% CI:0.79-0.98; P < 0.001) and interobserver (ICC: 0.93; 95% CI: -0.05 to 0.98; P < 0.001) agreements were shown. The new PPMI rate was 6.7% at 30 days without a significant difference between balloon-expandable valves and self-expandable valves (3.4% vs 8.7%; P = 0.226). Patients with a TAV implantation depth less than MS length had a significantly lower incidence of new PPMI compared with patients with a TAV implantation depth greater than MS length (2.1% vs 13.4%; P = 0.005), regardless of baseline right bundle branch block presence (6.7% vs 66.7%; P = 0.004) or absence (1.2% vs 8.2%; P = 0.041). Conclusions: TJ-ICE-guided TAVR demonstrated remarkable feasibility and safety. The TJ-ICE-guided final TAV position had a significant impact on the new PPMI rate. (Tokai Valve Registry; UMIN000036671).

Predictors for non-delayed discharge after transcatheter aortic valve replacement: utility of echocardiographic parameters.

Considering that transcatheter aortic valve replacement (TAVR) procedures have become less invasive, the duration for monitoring patient care after a successful TAVR can be reduced. Therefore, this study aimed to investigate the prognostic value of baseline echocardiographic parameters for non-delayed discharge in patients after TAVR. The study group included 154 consecutive patients (mean age: 84.4 ± 4.5 years; and 101 women) who underwent a TAVR. Comprehensive echocardiograms including both side indices of myocardial performance (IMP) and blood tests were obtained prior to the TAVR procedure. The median post-TAVR length of stay was 6 days while the mode and first quartile were both 4 days. Receiver operating characteristic curve analysis showed that the optimum cut-off value of the left-sided IMP in patients with a normal left ventricular ejection fraction (LVEF, ≥ 50%) (n = 124) for non-delayed discharge (≤ 4 days) was 0.34 with an area under the curve (AUC) value of 0.71563 and p value of < 0.0001, while the optimum cut-off value in patients with reduced LVEF (< 50%) (n = 30) was 0.47 with an AUC value of 0.77778 and p value of < 0.0120. An adjusted analysis indicated the negative left-sided IMP results as the only predictor for non-delayed discharge (p < 0.0001). Furthermore, the adjusted predictors for survival without early cardiovascular re-hospitalization within 6 months after TAVR were the positive left-sided IMP result, when the cut-off value of 0.52 was used, and the presence of elevated RAP of 8 to 15 mmHg. The early discharge policy should be carefully considered in high-risk populations, but the left-sided IMP may play a significant role in the pre-screening process.

Late-onset atrioventricular block after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances leading to permanent pacemaker implantation (PPI) rarely occur late after transcatheter aortic valve replacement (TAVR). The clinical features of this phenomenon and its association with periprocedural conduction disturbances remain uncertain. OBJECTIVES: We aimed to determine the incidence and characteristics of late-onset atrioventricular block (AVB) after TAVR. METHODS: This single-center study included 246 patients undergoing TAVR. Late-onset AVB was defined as AVB ≥1 month after the TAVR. RESULTS: Periprocedural AVB (periAVB) occurred in 43 patients (17%). Patients with periAVB had a higher rate of right bundle branch block (47% vs 7%, P < .0001). Of the 43 patients with periAVB, 15 underwent PPI (35%) at a median duration of 6 days, whereas 1 of the remaining 203 patients without periAVB underwent PPI within 1 month (0.5%). During a median follow-up duration of 365 days, late-onset AVB occurred in 10 of 230 patients without PPI within 1 month (4%) at a median duration of 76 days. All 10 patients presented transient periprocedural atrioventricular conduction disturbances, including 8 patients with periAVB (80%), all of whom recovered within 1 month, and 9 patients underwent self-expanding valve implantation (90%). The mortality rate in patients with PPI within 1 month was higher than in those without, although the difference was not statistically significant (hazard ratio 2.68, 95% confidence interval 0.97-9.05, log-rank P = .09). CONCLUSION: Late-onset AVB occurred in a minority of patients undergoing TAVR. Greater vigilance is warranted, particularly in patients with transient conduction disturbances during the periprocedural period following self-expanding valve implantation.

Efficacy of exogenous atrial natriuretic peptide in patients with heart failure with preserved ejection fraction: deficiency of atrial natriuretic peptide and replacement therapy.

AIMS: Exogenous atrial natriuretic peptide (ANP) may be a logical treatment for heart failure (HF) patients with ANP deficiency. Lower ANP concentrations may result from HF with preserved ejection fraction (HFpEF), which also results in lower brain natriuretic peptide levels in HFpEF relative to HF with reduced ejection fraction (HFrEF), although clinical features regarding circulating ANP in HFpEF and HFrEF have not been fully investigated during acute HF. Here, we characterized the differential regulation of circulating ANP and the efficacy of exogenous ANP (carperitide) in patients with acute HF, especially HFpEF. METHODS AND RESULTS: Serum ANP levels before treatment and the diuretic effect of 0.0125 µg/kg/min of carperitide alone for the first 6 h were prospectively evaluated in 113 patients with acute HF who were divided into two groups: HFpEF vs. HFrEF. We mainly analysed the impact of baseline ANP levels and the presence of HFpEF on the diuretic effect of exogenous ANP. There was an inverse relationship between ANP levels and the diuretic effect of exogenous ANP (r2  = 0.19, P < 0.001). Patients with HFpEF had lower ANP levels (P < 0.001) and a greater diuretic effect of exogenous ANP than patients HFrEF (P < 0.001). HFpEF was an independent predictor of greater diuretic effect of exogenous ANP (P = 0.003), as with a lower baseline ANP level (P = 0.004). CONCLUSIONS: Patients with HFpEF might have an aspect of ANP deficiency and represent a promising therapeutic target for modulating circulating ANP.

Impact of intravascular ultrasound-guided minimum-contrast coronary intervention on 1-year clinical outcomes in patients with stage 4 or 5 advanced chronic kidney disease.

This study aims to elucidate 1-year clinical outcomes using this technique for patients with stage 4 or 5 advanced chronic kidney disease (CKD). Research has proven that imaging-guided percutaneous coronary intervention (PCI) reduces contrast volume significantly; however, only short-term clinical benefits have been reported. Minimum-contrast (MINICON) studies are based on the registry design pattern to enroll PCI results in patients with advanced CKD stage 4 or 5 comorbid with coronary artery disease. We excluded cases of emergency PCI or maintenance dialysis from this study. In this study, we compared the intravascular ultrasound (IVUS)-guided MINICON PCI group (n = 98) with the angiography-guided standard PCI group (n = 86). Enrollment of the MINICON studies started in 2006. Before 2012, IVUS-guided MINICON PCI was performed only in 14% (stage 1), but it was 100% after 2012 (stage 2). The enrollment finished in 2016. The IVUS-guided MINICON PCI group exhibited a significantly reduced contrast volume (22 ± 20 vs. 130 ± 105 mL; P < 0.0001) and contrast-induced acute kidney injury (CI-AKI; 2% vs. 15%; P = 0.001). The PCI success rate was similarly high (100% vs. 99%; P = 0.35). At 1 year (follow-up rate, 100%), we observed less induction of renal replacement therapy (RRT; 2.7% vs. 13.6%; P = 0.01), but all-cause mortality or myocardial infarction was similar in both groups. The IVUS-guided MINICON PCI reduces CI-AKI significantly and induction of RRT at 1 year in patients with stage 4 or 5 advanced CKD.

Coronary flow improvement following unsuccessful primary percutaneous coronary intervention in ST-elevation myocardial infarction with diffuse ectatic coronary artery.

BACKGROUND: In ST-elevation myocardial infarction (STEMI) patients with diffuse ectatic coronary artery, extensive thrombi inhibit achievement of final successful revascularization of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow after primary percutaneous coronary intervention. However, clinical and angiographic outcomes of such patients are uncertain. The present study examined clinical and angiographic outcomes in STEMI incorporating giant coronary artery with diffuse ectasia. METHODS: Seven hundred and forty-four STEMI patients undergoing primary percutaneous coronary intervention were surveyed retrospectively. Culprit lesions in giant coronary artery with diffuse ectasia (Ectatic group, n=39) were investigated. Percutaneous coronary intervention success rate and angiographic or clinical outcomes at 360 days were compared with those of the Non-ectatic group ( n=705). RESULTS: Angiographic percutaneous coronary intervention success rate was significantly lower in the Ectatic group due to lower achievement of final TIMI grade 3 flow (53.8% vs. 92.9%, p<0.0001; 53.8% vs. 93.5%, p<0.0001, respectively). In follow-up angiography, 86% of the Ectatic group showed angiographic improvement from TIMI grade 2 or less immediately after percutaneous coronary intervention to TIMI grade 3 flow at follow-up. In contrast, angiographic improvement was observed in only 25% of cases in the Non-ectatic group. All-cause 360-day mortality was significantly lower in the ectatic group (2.6% vs. 14.5%, p=0.0361, respectively). CONCLUSION: In patients with STEMI in giant coronary artery with diffuse ectasia, achievement of TIMI grade 3 flow was significantly reduced immediately after percutaneous coronary intervention. However, improvement of coronary flow up to TIMI grade 3 was not uncommon at follow-up angiogram. Patients had low mortality despite low TIMI grade 3 achievement immediately after primary percutaneous coronary intervention.

A cardiac hemangioma treated by a right minithoracotomy approach with thoracoscopic assistance.

Cardiac hemangiomas are extremely rare tumors, accounting for only 2.5% of all cardiac tumors. Most of these develop in the ventricles, and obtaining a good field of view is, therefore, the key to successful operation. A 40-year-old female visited a local hospital due to palpitation. Transthoracic echocardiography revealed a spherical high-echo mass (13.5 × 10.7 mm in diameter) between the papillary muscles. She was referred to our hospital to undergo close examination. Cardiac contrast-enhanced magnetic resonance imaging was performed to differentiate between malignant and benign lesions. However, this did not provide any findings leading to a definite diagnosis. To make a diagnosis and prevent embolism, the mass was excised using a right minithoracotomy approach with thoracoscopic assistance. The post-operative pathological diagnosis was a cardiac capillary-cavernous hemangioma. A right minithoracotomy approach combined with thoracoscopy allowed accurate evaluation of the mass in the left ventricle beyond the mitral valve and its accurate excision.

Impact of the origin of the collateral feeding donor artery on short-term mortality in ST-elevation myocardial infarction with comorbid chronic total occlusion.

BACKGROUND: Patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease (MVD) have higher mortality, especially with comorbid chronic total occlusion (CTO). The origin of collateral flow to the CTO segment has not been studied in regard to short-term mortality. This study examined the impact of collateral feeding donor arteries from an infarct-related artery (IRA) or non-IRA to the comorbid CTO segment in regard to STEMI short-term mortality. METHODS: Data from 760 consecutive STEMI patients who underwent primary percutaneous coronary intervention were obtained retrospectively from medical records. The number of vessels involved and origin of the collateral feeding donor artery were evaluated using angiograms from the primary percutaneous coronary intervention. The study population was divided into patients with: single-vessel disease (SVD) (n=483), MVD without CTO (n=208), and MVD with CTO (n=64). All CTO segments had collateral flow from an IRA (n=23) or non-IRA (n=46). All-cause mortality (30-day) was analyzed. RESULTS: Compared to SVD and MVD without CTO, MVD with comorbid CTO had a higher mortality (5.4% vs. 15.9% vs. 24.6%, P<0.0001, respectively). Of patients with CTO, those with collateral flow from the IRA had significantly higher mortality than the non-IRA group (52.2% vs. 10.9%, P<0.0001). Collateral flow from the IRA was extracted as an independent predictor associated with 30-day all-cause mortality using a multivariate Cox proportional hazards model (hazard ratio 4.71, 95% confidence interval 1.60-14.2, P=0.0005). CONCLUSIONS: The origin of the collateral donor artery from the IRA had an impact on short-term mortality in STEMI patients with comorbid CTO lesions.