Urine albumin-to-creatinine ratio on admission predicts early rehospitalization in patients with acute decompensated heart failure.

Detecting high-risk patients for early rehospitalization is crucial in heart failure patient care. An association of albuminuria with cardiovascular events is well known. However, its predictive impact on rehospitalization for acute decompensated heart failure (ADHF) remains unknown. In this study, 190 consecutive patients admitted due to ADHF between 2017 and April 2019 who underwent urinalysis were enrolled. Among them, 140 patients from whom urine albumin-to-creatinine ratio (UACR) was measured with spot urine samples on admission were further analyzed. The association between UACR and rehospitalization due to HF during 1 year after discharge was evaluated. The mean age of 140 participants was 77.6 years and 55% were men. Only 18% (n = 25) of patients presented with normoalbuminuria (UACR < 30 mg/g∙creatinine), whereas 59% (n = 83) and 23% (n = 32) showed microalbuminuria (UACR 30-300 mg/g·creatinine) and macroalbuminuria (UACR > 300 mg/g·creatinine), respectively. The level of UACR on admission was correlated with the risk of subsequent rehospitalization due to HF (p = 0.017). The receiver operating characteristic analysis indicated that the best cut-off values for the UACR and B-type natriuretic peptide (BNP) levels to predict ADHF rehospitalization were 50 mg/g·creatinine and 824 pg/ml, respectively. When the patients were divided into four groups using both cut-off values, the individual predictive impacts of UACR and BNP on rehospitalization were comparable. Patients with both elevated UACR and BNP levels had a higher rate of HF rehospitalization than those with elevated BNP levels alone (p < 0.05). The combination of both values enabled more accurate prediction of HF rehospitalization than BNP levels alone. In conclusion, UACR could be a new useful biomarker to predict HF rehospitalization in patients with ADHF, especially in combination with the levels of BNP, and should be further evaluated in a prospective study.

Impact of Induced Therapeutic Hypothermia by Intravenous Infusion of Ice-Cold Fluids After Hospital Arrival in Comatose Survivors of Out-of-Hospital Cardiac Arrest With Initial Shockable Rhythm.

BACKGROUND: The effect of in-hospital rapid cooling by intravenous ice-cold fluids for comatose survivors of out-of-hospital cardiac arrest (OHCA) is unclear.Methods and Results:From the J-PULSE-HYPO study registry, data for 248 comatose survivors with return of spontaneous circulation (ROSC) who were treated with therapeutic hypothermia (34℃ for 12-72 h) after witnessed shockable OHCA were extracted. Patients were divided into 2 groups by the median collapse-to-ROSC interval (18 min), and then into 2 groups by cooling method (rapid cooling by intravenous ice-cold fluids vs. standard cooling). The primary endpoint was favorable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days after OHCA. In the whole cohort, the shorter collapse-to-ROSC interval group had significantly higher favorable neurological outcome than the longer collapse-to-ROSC interval group (78.2% vs. 46.8%, P<0.001). In the shorter collapse-to-ROSC interval group, no significant difference was observed in favorable neurological outcome between the 2 cooling groups (rapid cooling group: 79.4% vs. standard cooling group: 77.0%, P=0.75). In the longer collapse-to-ROSC interval group, however, favorable neurological outcome was significant higher in the rapid cooling group than in the standard cooling group (60.7% vs. 33.3%, P<0.01) and the adjusted odds ratio after rapid cooling was 3.069 (95% confidence interval 1.423-6.616, P=0.004). CONCLUSIONS: In-hospital rapid cooling by intravenous ice-cold fluids improved neurologically intact survival in comatose survivors whose collapse-to-ROSC interval was delayed over 18 min after shockable OHCA.

Relationship of Central Venous Pressure to Body Fluid Volume Status and Its Prognostic Implication in Patients With Acute Decompensated Heart Failure.

BACKGROUND: Although central venous pressure (CVP) is a surrogate measure of preload in patients with acute decompensated heart failure (ADHF), it is a multifactorial index influenced not only by fluid volume status, but also by cardiac pump function and other factors. We aimed to elucidate the individual pathophysiological factors of CVP elevation in patients with ADHF by assessing the relationship between CVP and extracellular fluid volume status (EVS). METHODS AND RESULTS: We quantified EVS in 100 patients with ADHF with the use of bioelectrical impedance analysis. CVP was also measured at the same time point. Subjects were categorized into tertiles according to their CVP-EVS ratios, and patient characteristics and clinical outcomes were compared among these tertiles. The upper-tertile group had a higher incidence of impaired right ventricular pump function, whereas the lower-tertile group had higher incidences of severe inflammation, hypoalbuminemia, and renal dysfunction. Patients in both the upper and lower tertiles had a significantly higher cardiac event rate than those in the middle tertile. CONCLUSIONS: The combined assessment of CVP and EVS provides insight into both the total volume status and distribution of body fluid in ADHF patients, and it may have applications in guiding decongestive therapy and improving prognostic predictions.

Impact of Preprocedural Serum Eicosapentaenoic Acid to Arachidonic Acid Ratio on Post-Ablation Recurrence of Atrial Fibrillation.

The aim of this study was to examine the impact of the serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio on recurrence after catheter ablation (CA) for atrial fibrillation (AF).A total of 192 patients who underwent first-time radiofrequency CA for AF were enrolled in this study. They were divided into two groups based on the median serum EPA/AA ratio before CA: a LOW group (< 0.30; n = 96) and a HIGH group (≥ 0.30; n = 96). Patients in the LOW group were younger and had smaller left atrial diameter (LAD) than those in the HIGH group. Although pulmonary vein triggers initiating AF were more frequently observed in the LOW group than the HIGH group (63% versus 46%, respectively; P = 0.021), no significant between-group difference was observed regarding the incidence of AF recurrence since the last procedure (17% versus 17%, P = 0.78; median follow-up, 37 months). Multivariate Cox regression analysis after adjustment for age and LAD revealed that EPA/AA of < 0.30 was not a significant predictor of AF recurrence (hazard ratio, 1.12; 95% confidence interval 0.53-2.37; P = 0.76). However, in the non-paroxysmal AF subgroup (n = 65), the incidence of AF recurrence was significantly higher in the LOW group than in the HIGH group (25.7% versus 6.7%, respectively; P = 0.031).In conclusion, a lower preprocedural EPA/AA ratio, which was associated with younger age and small left atrium, was not a predictor for the risk of AF recurrence after CA for AF. The potential impact of the ratio on recurrence in non-paroxysmal AF subgroups should be examined with larger samples.

The Impact of Heart Rate Response During 48-Hour Rewarming Phase of Therapeutic Hypothermia on Neurologic Outcomes in Out-of-Hospital Cardiac Arrest Patients.

OBJECTIVES: Bradycardia during therapeutic hypothermia has been reported to be a predictor of favorable neurologic outcomes in out-of-hospital cardiac arrests. However, bradycardia occurrence rate may be influenced by the target body temperature. During therapeutic hypothermia, as part of the normal physiologic response, heart rate decreases in the cooling phase and increases during the rewarming phase. We hypothesized that increased heart rate during the rewarming phase is another predictor of favorable neurologic outcomes. To address this hypothesis, the study aimed to examine the association between heart rate response during the rewarming phase and neurologic outcomes in patients having return of spontaneous circulation after out-of-hospital cardiac arrest. DESIGN: A secondary analysis of the Japanese Population-based Utstein style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia registry, which was a multicenter prospective cohort study. SETTING: Fourteen hospitals throughout Japan. PATIENTS: Patients suffering from out-of-hospital cardiac arrest who received therapeutic hypothermia after the return of spontaneous circulation from 2005 to 2011. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: This study enrolled 452 out-of-hospital cardiac arrest patients, of which 354 were analyzed, and 80.2% survived to hospital discharge, of which 57.3% had a good neurologic outcome. Heart rate response was calculated using heart rate data recorded during therapeutic hypothermia in the abovementioned registry. Heart rate response in the rewarming phase (heart rate response-rewarming) was calculated as follows: (heart rate [post rewarming]-heart rate [pre rewarming])/heart rate (pre rewarming) × 100. The primary outcome was an unfavorable neurologic outcome at hospital discharge, that is, a Cerebral Performance Category of 3-5. Multivariable logistic regression analysis was performed to determine the association between heart rate response-rewarming and unfavorable neurologic outcomes. Multivariable logistic regression analysis showed that heart rate response-rewarming was independently associated with unfavorable outcomes (odds ratio [per 10% change], 0.86; 95% CI, 0.78-0.96; p = 0.004). CONCLUSIONS: Increased heart rate in the approximately 48-hour rewarming phase during therapeutic hypothermia was significantly associated with and was an independent predictor of favorable neurologic outcomes during out-of-hospital cardiac arrest.

Evaluation of Need for Implantable Cardioverter-Defibrillator by Thallium-201 Scintigraphy Among Japanese Patients With Prior Myocardial Infarction.

BACKGROUND: Identifying who among current Japanese patients with prior myocardial infarction (MI) would benefit from an implantable cardioverter-defibrillator (ICD) is imperative. Accordingly, this study seeks to determine whether single-photon emission computed tomography (SPECT) can help identify such patients. Methods and Results: This retrospective study enrolled 60 consecutive patients with prior MI who underwent stress thallium-201 SPECT and ICD implantation from February 2000 to October 2014. Occurrence of arrhythmic death and/or or appropriate ICD therapy, defined as shock or antitachycardia pacing for ventricular fibrillation or tachycardia, was identified until November 2016. During the median follow-up interval of 6.6 years, 18 (30%) patients experienced arrhythmic death and/or appropriate ICD therapy. Multivariate Cox proportional hazard regression analysis revealed that the summed stress score (SSS) [hazard ratio (HR)=1.14; P=0.005] and left ventricular ejection fraction (LVEF) at rest (HR=0.92; P=0.038) were significantly associated with the occurrence of arrhythmic events. Patients with SSS ≥21 and LVEF ≤30%, which were determined to be the best cutoff points, had significantly higher incidence of the arrhythmic events than the other patients (64% vs. 11%; HR=7.18; log-rank P=0.001). CONCLUSIONS: SSS using stress thallium-201 SPECT in combination with LVEF can help determine the need for ICD therapy among current Japanese patients with prior MI.

Differences in amiodarone efficacy in relation to ejection fraction and basal rhythm in patients with implantable cardioverter defibrillators.

BACKGROUND: Atrial fibrillation (AF) and ventricular arrhythmias (VAs) are associated with increased morbidity and mortality. However, data are lacking concerning the association of AF and VAs. This study aimed to clarify the association between AF and VAs and to investigate the effect of amiodarone on the incidence of VAs in patients with implantable cardioverter defibrillators (ICDs). METHODS AND RESULTS: We enrolled 612 patients who had ICDs or who underwent cardiac resynchronization therapy with a defibrillator (CRT-D) and classified them into two groups (sinus rhythm [SR] group, n = 427; AF group, n = 185) according to their basal rhythm at enrollment. Patients with paroxysmal AF were grouped into the AF group. The incidence of VAs, i.e., ventricular tachycardia (VT) and ventricular fibrillation (VF), was significantly lower in the AF group than in the SR group (0.54 vs 0.95 episodes/person/year, P = 0.032). Furthermore, amiodarone use was significantly higher in the AF group than in the SR group (P = 0.003). Non-use of amiodarone was associated with a significant increase in the occurrence of VT/VF in the two groups. This beneficial suppressive effect of amiodarone on the incidence of VT/VF was present in the AF group regardless of left ventricular ejection fraction (LVEF). However, this effect of amiodarone was present only in patients with LVEF ≥ 40% in the SR group. CONCLUSIONS: Amiodarone was negatively associated with VT/VF occurrence and was frequently used in ICD/CRT-D patients with AF. VT/VF was controlled by amiodarone in all cases in the AF group but only in patients with an LVEF ≥ 40% in the SR group.

Clinical Influence and Predictors of Pacing-Induced Mechanical Asynchrony in Patients with Normal Cardiac Function with Ventricular Lead Placed in Non-Apical Position.

Right ventricular apical (RVA) pacing often causes left ventricular (LV) mechanical asynchrony, which is enhanced by impaired cardiac contraction and intrinsic conduction abnormality. However, data on patients with normal cardiac function and under RV non-apical (non-RVA) pacing are limited.We retrospectively investigated 97 consecutive patients with normal ejection fraction who received pacemaker implantation for atrioventricular block with the ventricular lead placed in a non-RVA position. We defined mechanical asynchrony as discoordinate contraction between opposing regions of the LV wall evaluated by echocardiography. Asynchrony was detected in 9 (9%) patients at baseline and in 38 (39%) under non-RVA pacing (P < 0.001). Asynchrony at baseline was significantly associated with complete left bundle branch block (CLBBB) [odds ratio (OR) = 20.8, P < 0.001]. Asynchrony under non-RVA pacing was significantly associated with left anterior fascicular block (LAFB) (OR = 7.14, P < 0.001) and CLBBB (OR = 13.3, P = 0.002) at baseline. New occurrence of asynchrony was significantly associated with LAFB at baseline (OR = 5.88, P = 0.001). During a median follow-up period of 4.8 years, the incidence of device-detected atrial fibrillation (AF) was more frequent in patients who developed asynchrony than in those who did not (53.3% versus 27.5%, hazard ratio = 2.17, 95% confidence interval = 1.02-4.61, P = 0.03).In patients with normal cardiac function, LAFB at baseline was significantly associated with new occurrence of mechanical asynchrony under non-RVA pacing. Abnormal contraction had a significant influence on the incidence of device-detected AF.

Angioplasty of the Occluded Persistent Sciatic Artery Using the Retrograde Approach from Superficial Femoral Artery.

Persistent sciatic artery is a rare developmental anomaly prone to atherosclerotic disease. We present a case of successful endovascular therapy for left persistent sciatic artery that was occluded at the distal site. The angioplasty was performed with both antegrade approach from contralateral common femoral artery and retrograde approach from ipsilateral superficial femoral artery. The guidewire was advanced via collateral channel and crossed through the lesion retrogradely. Rendez-vous technique was performed, and the lesion was successfully dilated by balloon inflation. Angioplasty of occluded sciatic artery can be performed successfully and effectively using the collateral channel.

Transtubular Potassium Concentration Gradient as a Surrogate Measure of Arterial Underfilling in Acute Decompensated Heart Failure.

BACKGROUND: The monitoring of tissue hypoperfusion and the subsequent neurohumoral activation (ie, arterial underfilling) during decongestion is important for the management of acute decompensated heart failure (ADHF). The transtubular potassium concentration gradient (TTKG) has been reported to be a marker of renal aldosterone bioactivity. This study tested the hypothesis that TTKG can be a surrogate of arterial underfilling in patients with ADHF. METHODS AND RESULTS: We measured TTKG at discharge in 100 ADHF patients. The primary outcome measure was the occurrence of tissue hypoperfusion events (defined according to the "Cold Modified 2014" definition criteria) within 1 month after discharge. The secondary outcome measure was the occurrence of cardiac death or ADHF readmission within 3 months after discharge. On receiver operating characteristic curve analysis, TTKG predicted tissue hypoperfusion events with high accuracy (C-statistic, 0.889) for a cut-off of 6.0. Multivariate Cox regression analyses demonstrated independent relationships between TTKG and both the primary and secondary outcomes. CONCLUSIONS: TTKG has utility as a surrogate of arterial underfilling, and spot TTKG at discharge may be a prognostic marker in ADHF patients. (Circ J 2016; 80: 1965-1970).

Angioscopic Comparison of Resolute and Endeavor Zotarolimus-Eluting Stents.

BACKGROUND: Drug-eluting stents (DES) have reduced late loss and target lesion revascularization through the inhibition of neointimal hyperplasia, but instead increased the risk of very late stent failure due to incomplete neointimal coverage and neoatherosclerosis. Although newer DES are more effective and safer than the first-generation DES, the difference in the condition of the stented lesions between Resolute zotarolimus-eluting stents (R-ZES) and Endeavor zotarolimus-eluting stents (E-ZES) on angioscopy has not been reported. METHODS AND RESULTS: Consecutive patients who received R-ZES (n=46) or E-ZES (n=46) for de novo lesion of native coronary artery and had 1-year follow-up angioscopy were examined. Yellow color (grade 0-3), neointimal coverage (grade 0-2), heterogeneity score (maximum-minimum neointimal coverage grade) and thrombus (presence or absence) at stented lesion were evaluated. The maximum yellow color grade (1.2±0.9 vs. 0.7±1.0, P=0.005) was higher in R-ZES than in E-ZES. The maximum (1.9±0.3 vs. 1.5±0.5, P<0.001) and minimum (1.1±0.7 vs. 0.4±0.5, P<0.001) coverage grade was higher in E-ZES than in R-ZES. The heterogeneity score was higher in R-ZES than in E-ZES (1.0±0.5 vs. 0.7±0.7, P=0.007). Prevalence of thrombus was not different between the 2 stents (6.5% vs. 2.2%, P=0.4). CONCLUSIONS: E-ZES had better neointimal coverage with less yellow plaque and lower heterogeneity score than R-ZES. The lesions with E-ZES appeared more stable than those with R-ZES. (Circ J 2016; 80: 650-656).

Bacterial Contamination During Pacemaker Implantation Is Common and Does Not Always Result in Infection.

BACKGROUND: Bacterial cultures of cardiovascular implantable electronic devices removed from patients without clinical infection are often positive, and the cultured bacteria are different from those at the time of clinical infection. This discrepancy has not been adequately explained. We hypothesized that the cause is bacterial contamination at operation and compared the results of bacterial cultures between patients with de novo pacemaker implantation and those with pacemaker replacement. METHODS AND RESULTS: We prospectively enrolled consecutive 100 patients who underwent cardiac pacemaker implantation (49 de novo implantations, 51 replacements). We took swab cultures from inside the generator pocket (1) immediately after the creation of new pocket or removal of old generator, (2) after connection of leads to new generator, and (3) after pocket lavage. Swab cultures were positive in 272 (45%) of 600 samples. The majority of the cultured bacteria were Propionibacterium species. No statistical difference was detected between de novo implantations and replacements in the positive ratio of swab cultures. The positive ratio was not correlated with the number of previous device replacements. CONCLUSIONS: The positive ratio of swab cultures was not different between new implantations and replacements, suggesting that a positive culture merely indicates contamination of bacteria during operation rather than colonization.

Effect of Admission Glasgow Coma Scale Motor Score on Neurological Outcome in Out-of-Hospital Cardiac Arrest Patients Receiving Therapeutic Hypothermia.

BACKGROUND: Because the initial (on admission) Glasgow Coma Scale (GCS) examination has not been fully evaluated in comatose survivors of cardiac arrest (CA) who receive therapeutic hypothermia (TH), the aim of the present study was to determine any association between the admission GCS motor score and neurologic outcomes in patients with out-of-hospital CA who receive TH. METHODS AND RESULTS: In the J-PULSE-HYPO study registry, patients with bystander-witnessed CA were eligible for inclusion. Patients were divided into 3 groups based on GCS motor score (1, 2-3, and 4-5) to assess various effects on neurologic outcome. Univariate and multivariate analyses were performed to identify independent predictors of good neurologic outcome at 90 days. Of 452 patients, 302 were enrolled. There was a significant difference among the 3 patient groups with regard to neurologic outcome at 90 days in the univariate analysis. Multiple logistic regression analyses showed that the GCS motor score on admission, age >65 years, bystander cardiopulmonary resuscitation, the time from collapse to return of spontaneous circulation, and pupil size <4 mm were independent predictors of a good neurologic outcome at 90 days in cases of CA (GCS motor score, 4-5: odds ratio, 8.18; 95% confidence interval: 1.90-60.28; P<0.01). CONCLUSIONS: GCS motor score is an independent predictor of good neurologic outcome at 90 days in patients sustaining out-of-hospital CA who receive TH.

Association of target lesion characteristics evaluated by coronary computed tomography angiography and plaque debris distal embolization during percutaneous coronary intervention.

BACKGROUND: The slow-flow or no re-flow phenomenon has been associated with distal embolization, especially of plaque debris, and with unfavorable clinical outcomes. Therefore, we examined the association between the coronary computed tomography angiography (CCTA) findings of the target lesion and distal embolization during percutaneous coronary intervention (PCI). METHODS AND RESULTS: Consecutive patients (n=55: 18 unstable angina, 19 stable effort angina, 18 silent ischemia) who underwent PCI with a filter-type distal protection device after evaluation of the target lesion by CCTA were analyzed. CCTA examined low-attenuation plaque (LAP), positive remodeling (PR), and ring-like enhancement of the target lesion. Distal embolization of thrombus and plaque debris was evaluated by pathological examination of material collected in the filter.Any distal embolization and distal embolization of plaque debris were respectively detected in 75% and 0% of patients with LAP or PR alone, in 95% and 17% of patients with both LAP and PR, and in 100% and 27% of patients with all of LAP, PR and ring-like enhancement. The sensitivity and specificity to predict plaque debris embolization by having both findings of LAP and PR was 100% and 46%, respectively. CONCLUSIONS: The CCTA findings of the target lesion were associated with distal embolization and were very sensitive for predicting plaque debris embolization.

Atherosclerotic change at one year after implantation of Endeavor zotarolimus-eluting stent vs. everolimus-eluting stent.

BACKGROUND: Atherosclerosis progression is thought to be one of the mechanisms of late stent failure. Atherosclerosis progression is detected as yellow plaque formation on angioscopy. Cypher sirolimus-eluting stent has been reported to accelerate atherosclerosis progression, but the influence of Endeavor zotarolimus-eluting stent (Endeavor-ZES) or Xience everolimus-eluting stent (Xience-EES) on atherosclerosis has not been clarified. Therefore, we examined the serial changes in extent of atherosclerosis after the implantation of Endeavor-ZES or Xience-EES. METHODS AND RESULTS: Consecutive patients who received implantation of Endeavor-ZES (n=25) or Xience-EES (n=30) at de novo lesion of native coronary artery and who had successful angioscopy immediately after stent implantation (baseline) and at 1-year follow-up were included in the study. Change in the maximum yellow color grade (grade 0-3) of the stented segment from baseline to follow-up was examined and was compared between Endeavor-ZES and Xience-EES. The maximum yellow color grade decreased significantly from baseline to follow-up in Endeavor-ZES (1.6±1.1 vs. 0.4±0.8, P<0.001), but it did not change in Xience-EES (1.7±1.0 vs. 1.4±0.7, P=0.23). Although the maximum yellow color grade was not different between Endeavor-ZES and Xience-EES at baseline (P=0.72), it was significantly lower in Endeavor-ZES than in Xience-EES at follow-up (P<0.001). CONCLUSIONS: Atherosclerosis evaluated by yellow color of the plaque was significantly reduced at 1 year after Endeavor-ZES implantation, but was not changed after Xience-EES implantation.

Efficacy of anti-tachycardia pacing for terminating fast ventricular tachycardia in Japanese implantable cardioverter defibrillator patients. Primary results of the SATISFACTION study.

BACKGROUND: Anti-tachycardia pacing (ATP) delivered by implantable cardioverter defibrillators (ICD) safely avoids painful shocks with minimum risk of tachycardia acceleration. The etiology of ventricular tachycardia (VT) in those studies, however, was predominantly coronary artery disease (CAD). Patient etiology differs by geography and could affect ATP efficacy rate. The primary objective of this study was to examine how often the first ATP therapy terminates fast VT (FVT) in Japanese ICD patients with regional etiologies. METHODS AND RESULTS: Seven hundred and fifteen patients received ICD or cardiac resynchronization therapy defibrillator with the function of ATP during capacitor charging. The primary endpoint was the first ATP success rate for terminating FVT with cycle length 240-320 ms. During a mean follow-up of 11.3 months, 888 spontaneous VT episodes were detected, including 276 FVT (31.1%) in 42 patients. The first-ATP success rate for FVT in the overall group (41% CAD, 59% non-CAD including 23% idiopathic VT) was 62.1% (61.7% adjusted). Success rate was not different between non-CAD and CAD patients (61.4% adjusted and 57.5% adjusted, respectively, P=0.75). Eight FVT episodes (2.9%) accelerated after the first ATP attempt, all of which were terminated by subsequent device therapy (additional ATP or shock). CONCLUSIONS: ATP efficacy for FVT was similar between ICD patients with and without CAD etiology.

Regression of luminal stenosis at the site of silent plaque disruption in the era of optimal medical therapy. Low high-density lipoprotein cholesterol level isa potential risk of stenosis progression.

BACKGROUND: Plaque disruption and its healing is thought to be the major mechanism of atherosclerosis, but the contribution of silent plaque disruption to luminal stenosis progression has not been fully clarified. The aim of this study was therefore to examine the change in luminal stenosis at the site of silent plaque disruption. METHODS AND RESULTS: Consecutive patients (n=36) who received coronary angiography and angioscopy that identified silent plaque disruption (baseline) and had repeated coronary angiography later (follow-up) were included for analysis. Silent plaque disruption was defined as plaque with thrombus detected in non-culprit segments. Diameter stenosis of the site was angiographically measured at baseline and at follow-up, and their difference was defined as stenosis change. Statin was used in 89% of study patients, and serum low-density lipoprotein cholesterol level was 91 ± 21 mg/dl. The diameter stenosis decreased significantly from baseline to follow-up at 12 ± 4 months (32 ± 14% vs. 27 ± 14%, P<0.001), and the stenosis change was -5.6 ± 7.9%. High-density lipoprotein cholesterol (HDL-C) was significantly associated with stenosis change (r=-0.51, P=0.001) and was the only factor significantly associated with stenosis change. CONCLUSIONS: In the era of optimal medical therapy with statin, the site of silent plaque disruption showed significant regression of luminal stenosis. Nevertheless, serum HDL-C was inversely associated with stenosis change, and its low level remained as a potential risk of luminal stenosis progression at the site of silent plaque disruption.

Recurrent pericardial effusion caused by pacemaker lead perforation and warfarin therapy at seven years after implantation.

A 66-year-old man was implanted with a pacemaker. Seven years after implantation he was admitted due to cardiogenic cerebral embolism and warfarin therapy was introduced. After that, he suffered recurrent pericardial effusion for unexplained reasons. An exploratory thoracotomy revealed that the screw of the atrial lead had penetrated through the right auricular appendage wall.

Neurological benefit of therapeutic hypothermia following return of spontaneous circulation for out-of-hospital non-shockable cardiac arrest.

BACKGROUND: Although therapeutic hypothermia is an effective therapy for comatose adults experiencing out-of-hospital shockable cardiac arrest, there is insufficient evidence that is also applicable for those with out-of-hospital non-shockable cardiac arrest. METHODS AND RESULTS: Of 452 comatose adults treated with therapeutic hypothermia after return of spontaneous circulation (ROSC) subsequent to an out-of-hospital cardiac arrest of cardiac etiology, 372 who had a bystander-witnessed cardiac arrest, target core temperature of 32-34°C and cooling duration of 12-72 h were eligible for this study (75 cases of non-shockable cardiac arrest, 297 cases of shockable cardiac arrest). The median collapse-to-ROSC interval was significantly longer in the non-shockable group than in the shockable group (30 min vs. 22 min, P=0.008), resulting in a significantly lower frequency of 30-day favorable neurological outcome in the non-shockable group compared with the shockable group (32% vs. 66%, P<0.001). However, an analysis of data in quartiles assigned to varying lengths of collapse-to-ROSC interval revealed a similar frequency of 30-day favorable neurological outcome among both groups when the collapse-to-ROSC interval was ≤16 min (90% non-shockable group vs. 92% shockable group; odds ratio 0.80, 95% confidence interval 0.09-7.24, P=0.84). CONCLUSIONS: Post-ROSC cooling is an effective treatment for patients with non-shockable cardiac arrest when the time interval from collapse to ROSC is short.

Acute changes in the pacing threshold after lead implantation. Comparison between retractable and sweet-tip active-fixation leads.

Although the pacing threshold of steroid-eluting active-fixation leads remains stable over the long term, it changes rapidly after screw-in. We compared the pacing threshold in the acute phase between retractable and Sweet-Tip active-fixation leads. We studied 132 patients who were implanted with active-fixation leads for new pacemaker implantation or additional leads required due to disconnected/leaking leads. Pacing threshold was measured at 4 time points: before screw-in, immediately, and 5 and 10 minutes after screw-in. If the pacing threshold was > 1.5 volts (V) at 5 minutes, we changed the pacing site so that it became ≤ 1.5 V. A total of 169 retractable leads (Medtronic: 107 leads, St. Jude Medical: 62 leads) and 33 Sweet-Tip leads (Boston: 33 leads) were implanted. Eighty-nine leads were implanted in the atrium and 113 leads in the ventricle. Seventy patients were implanted with both atrial and ventricular leads. The pacing threshold of Sweet-Tip leads increased immediately after screw-in, while that of retractable leads decreased (Sweet-Tip: 0.20 ± 0.57 V, Retractable: -0.15 ± 0.53 V, P < 0.05). The pacing threshold of both types of leads decreased similarly from immediately to 5 minutes after screw-in (Sweet Tip: -0.29 ± 0.43 V, Retractable: -0.25 ± 0.36 V, P = NS). Few changes in the threshold were detected between 5 and 10 minutes. Because the pacing threshold of Sweet-Tip active-fixation leads increased immediately after screw-in and that of both type leads decreased from immediately to 5 minutes, we should measure the pacing threshold from 5 minutes after screw-in.