Raise-up technique for the creation of left atrial roof lesion: A useful technique with cryoballoon for persistent atrial fibrillation.

INTRODUCTION: Recent studies have reported the efficacy of the cryoballoon (CB)-guided left atrial roof block line (LARB) creation in patients with persistent atrial fibrillation (AF). However, it can be technically challenging to attach the balloon to the left atrial (LA) roof due to its anatomical variations. We designed a new procedure called the "Raise-up Technique," which may facilitate the firm adhesion of the CB to the LA roof during freezing. This study aimed to evaluate the efficacy of the Raise-up technique in LARB creation. METHODS AND RESULTS: In total, 100 consecutive patients with persistent AF who underwent CB-LARB creation were enrolled. Fifty-seven patients underwent LARB creation using the Raise-up technique (Raise-up group), and the remaining 43 did not use it (control group). The Raise-up technique was performed as follows: An Achieve catheter was inserted as deeply as possible into the upper branch of the right superior pulmonary vein to anchor the CB. The balloon was placed below the targeted site on the LA roof and frozen. When the temperature of the CB reached approximately -10°C and the CB was easier to attach to the LA tissue, the CB was raised and pressed against the LA roof immediately by sheath advancement. Then the balloon could be in firm contact with the target site on the roof. If necessary, additional sheath advancement after sufficient freezing (-20°C to -30°C) was allowed the CB to have more firm and broad contact with the target site. LARB creation without touch-up ablation was achieved in 54 of 57 patients (94.7%) in the Raise-up group and 33 of 43 patients (76.7%) in the control group (p < .05). The lesion size of the LARB in the Raise-up group was significantly larger than that in the control group (15.2 cm2 vs. 12.8 cm2, p < .05). Moreover, the width of the LARB lesion in the Raise-up group was wider than that in the control group (32.0 mm vs. 26.6 mm, p < .05). CONCLUSION: The Raise-up technique enabled the creation of seamless and thick LARB lesions with a single stroke. In addition, the CB-LARB lesions created using the Raise-up technique tended to be large, resulting in extensive debulking of the LA posterior wall arrhythmia substrates. In CB ablation for persistent AF, the Raise-up technique can be considered one of the key strategies for LARB creation.

Clinical Features of 544 Patients With Ruptured Aortic Aneurysm　- A Report From the Tokyo Acute Aortic Super Network Database.

BACKGROUND: Epidemiological data on ruptured aortic aneurysms from large-scale studies are scarce. The aims of this study were to: clarify the clinical course of ruptured aortic aneurysms; identify aneurysm site-specific therapies and outcomes; and determine the clinical course of patients receiving conservative therapy.Methods and Results: Using the Tokyo Acute Aortic Super Network database, we retrospectively analyzed 544 patients (mean [±SD] age 78±10 years; 70% male) with ruptured non-dissecting aortic aneurysms (AAs) after excluding those with impending rupture. Patient characteristics, status on admission, therapeutic strategy, and outcomes were evaluated. Shock or pulselessness on admission were observed in 45% of all patients. Conservative therapy, endovascular therapy (EVT), and open surgery (OS) accounted for 32%, 23%, and 42% of cases, respectively, with corresponding mortality rates of 93%, 30%, and 29%. The overall in-hospital mortality rate was 50%. The prevalence of pulselessness was highest (48%) in the ruptured ascending AA group, and in-hospital mortality was the highest (70%) in the ruptured thoracoabdominal AA group. Multivariable logistic regression analysis indicated in-hospital mortality was positively associated with pulselessness (odds ratio [OR] 10.12; 95% confidence interval [CI] 4.09-25.07), and negatively associated with invasive therapy (EVT and OS; OR 0.11; 95% CI 0.06-0.20). CONCLUSIONS: The outcomes of ruptured AAs remain poor; emergency invasive therapy is essential to save lives, although it remains challenging to reduce the risk of death.

A new insight into superacute care for type A acute aortic dissection in the Tokyo Acute Aortic Super Network.

OBJECTIVE: To determine the status of type A acute aortic dissection using the Tokyo Acute Aortic Super Network. METHODS: Data of 6283 patients with acute aortic dissection between 2015 and 2019 were collected. Data of 3303 patients with type A acute aortic dissection were extracted for analysis. RESULTS: Overall, 51.0% of patients were nondirect admissions. On arrival, 23.1% of patients were in shock, 10.0% in cardiopulmonary arrest, and 11.8% in deep coma or coma. Overall, 9.8% of patients were assessed as untreatable. Of 2979 treatable patients, 18.3% underwent medical treatment, whereas 80.7% underwent surgery (open [78.8%], endovascular [1.9%], and peripheral [1.1%] repair). The early mortality rate was 20.5%, including untreatable cases. Among treatable patients, in-hospital mortality rates were 8.6% for open repair, 10.7% for endovascular repair, and 25.3% for medical treatment. Advanced age, preoperative comorbidities, classical dissection, and medical treatment were risk factors for in-hospital mortality. Nondirect admission did not cause increased deaths. The mortality rates were high during the superacute phase following symptom onset. CONCLUSIONS: This study demonstrated current practices in the emergency care of type A acute aortic dissection via the Tokyo Acute Aortic Super Network system, specifically a high rate of untreatable or inoperable cases and favorable outcomes in patients undergoing surgical treatment. High mortality rates were observed during the super acute phase after symptom onset or hospital arrival.

Outcomes of type A acute aortic dissection with cardiopulmonary arrest: Tokyo Acute Aortic Super-network Registry.

OBJECTIVES: Preventing loss of life in patients with type A acute aortic dissection (AAD) who present with cardiopulmonary arrest (CPA) can be extremely difficult. Thus, we investigated the early outcomes in these patients. METHODS: Patients with type A AAD who were transported to hospitals belonging to the Tokyo Acute Aortic Super-network between January 2015 and December 2019 were considered for this study. We assessed the early mortality of these patients presenting with CPA and also investigated the differences in outcomes between patients with out-of-hospital and in-hospital CPA. RESULTS: A total of 3307 patients with type A AAD were transported, 434 (13.1%) of whom presented with CPA. The overall mortality of patients presenting with CPA was 88.2% (383/434), of which 94.5% (240/254) experienced out-of-hospital CPA and 79.4% (143/180) experienced in-hospital CPA (P < 0.001). Multivariable analysis revealed that aortic surgery [odds ratio (OR), 0.022; 95% confidence interval (CI), 0.008-0.060; P < 0.001] and patient age over 80 years (OR, 2.946; 95% CI, 1.012-8.572; P = 0.047) were related with mortality in patients with type A AAD and CPA. Between in-hospital and out-of-hospital CPA, the proportions of DeBakey type 1 (OR, 2.32; 95% CI, 1.065-5.054; P = 0.034), cerebral malperfusion (OR, 0.188; 95% CI, 0.056-0.629; P = 0.007), aortic surgery (OR, 0.111; 95% CI, 0.045-0.271; P = 0.001), age (OR, 0.969; 95% CI, 0.940-0.998; P = 0.039) and the time from symptom onset to hospital admission (OR, 1.122; 95% CI, 1.025-1.228; P = 0.012) were significantly different. CONCLUSIONS: Patients with type A AAD presenting with CPA exhibited extremely high rates of death. Patient outcomes following in-hospital CPA tended to be better than those following out-of-hospital CPA; however, this difference was not significantly different. To prevent deaths, aortic surgery, when possible, should be considered in patients with type A AAD who sustained CPA.

Usefulness of Balloon-Assisted Ultrasound-Guided Percutaneous Thrombin Injection to Femoral Artery Pseudoaneurysm by Transradial Artery Approach.

Balloon-Assisted Ultrasound-Guided Percutaneous Thrombin Injection (BATI) is useful for iatrogenic pseudoaneurysm. In previous reports, BATI for pseudoaneurysm of the femoral artery was performed by contralateral transfemoral approach. It has been reported that patients with obesity, hypertension, and diabetes have more hemorrhagic complications at the puncture site of the femoral artery. We report a case in which BATI by transradial artery approach was useful for patients with obesity, hypertension, and diabetes who were expected to be at high risk of hemorrhagic complications of transfemoral artery approach.

Impact of Selenium Deficiency on Clinical Outcomes in Newly Diagnosed Heart Failure Patients in Japan.

Previous studies conducted have reported higher mortality and heart failure readmission rates in heart failure patients with selenium deficiency. However, these studies included patients with advanced heart failure, which may have confounded the relationship between selenium deficiency and heart failure pathology. This study aimed to explore the clinical characteristics and outcomes of heart failure patients with selenium deficiency who were newly diagnosed and hospitalized for heart failure in Japan. A total of 256 patients, who were admitted to our hospital for the first time due to heart failure, were included in this study. The patients were divided into two groups: a low selenium group (LS group, n=132) and a normal selenium group (NS group, n=124). Clinical features and outcomes were compared between the two groups, including 1-y mortality and readmissions due to heart failure. Among the patients admitted with heart failure, 51.6% exhibited selenium deficiency. The LS group showed a higher proportion of females (65.4% vs. 46.4%, p=0.003) and lower albumin levels (3.2±0.5 g/dL vs. 3.5±0.5 g/dL, p<0.001) compared to the NS group. The LS group had a significantly higher readmission rate for heart failure (31.8% vs. 17.7%, p=0.009). Multivariate analysis revealed heart failure patients with low selenium as an independent factor for readmission due to heart failure. Newly diagnosed heart failure patients with low selenium demonstrated a high readmission rate for heart failure.

In-Hospital Mortality of Patients With Acute Type A Aortic Dissection Hospitalized on Weekends Versus Weekdays.

Background: In acute aortic dissection, weekend admissions are reported to be associated with increased mortality compared with weekday admissions. Objective: This study aimed to determine whether patients with acute type A aortic dissection (ATAAD) admitted on weekends had higher in-hospital mortality than those admitted on weekdays in the Tokyo metropolitan area, where we developed a patient-transfer system for aortic dissection. Methods: Data were collected during the first year after our transfer system began (cohort I) and in the subsequent years from 2013 to 2015 (cohort II). Results: We studied 2,339 patients (500 in cohort I; 1,839 in cohort II) with ATAAD. Patients with weekend admissions had higher in-hospital mortality than those with weekday admissions in cohort I. In association with increased interfacility transfer during weekends and reduced mortality at non-high-volume centers, the in-hospital mortality in the weekend group improved from 37.2% in cohort I to 22.2% in cohort II (P < 0.001). After inverse probability weighting adjustment, weekend admission was associated with higher in-hospital mortality in cohort I (odds ratio: 2.28; 95% confidence interval: 1.48 to 3.52; P < 0.001), but not in cohort II (odds ratio: 0.96; 95% confidence interval: 0.75 to 1.22; P = 0.731). On multivariable analyses, weekend admission was associated with higher in-hospital mortality in combined cohort I+II; the associations between weekend admission and mortality were not significant in cohort II. Conclusions: We found a significant reduction in in-hospital mortality in patients with weekend admissions for ATAAD. No mortality difference between weekend and weekday admissions was observed in the later years of the study.

Sex-Related Differences in Clinical Features and In-Hospital Outcomes of Type B Acute Aortic Dissection: A Registry Study.

Background The association between female sex and poor outcomes following surgery for type A acute aortic dissection has been reported; however, sex-related differences in clinical features and in-hospital outcomes of type B acute aortic dissection, including classic aortic dissection and intramural hematoma, remain to be elucidated. Methods and Results We studied 2372 patients with type B acute aortic dissection who were enrolled in the Tokyo Acute Aortic Super-Network Registry. There were fewer and older women than men (median age [interquartile range]: 76 years [66-84 years], n=695 versus 68 years [57-77 years], n=1677; P<0.001). Women presented to the aortic centers later than men. Women had a higher proportion of intramural hematoma (63.7% versus 53.7%, P<0.001), were medically managed more frequently (90.9% versus 86.3%, P=0.002), and had less end-organ malperfusion (2.4% versus 5.7%, P<0.001) and higher in-hospital mortality (5.3% versus 2.7%, P=0.002) than men. In multivariable analysis, age (per year, odds ratio [OR], 1.06 [95% CI, 1.03-1.08]; P<0.001), hyperlipidemia (OR, 2.09 [95% CI, 1.13-3.88]; P=0.019), painlessness (OR, 2.59 [95% CI, 1.14-5.89]; P=0.023), shock/hypotension (OR, 2.93 [95% CI, 1.21-7.11]; P=0.017), non-intramural hematoma (OR, 2.31 [95% CI, 1.32-4.05]; P=0.004), aortic rupture (OR, 26.6 [95% CI, 14.1-50.0]; P<0.001), and end-organ malperfusion (OR, 4.61 [95% CI, 2.11-10.1]; P<0.001) were associated with higher in-hospital mortality, but was not female sex (OR, 1.67 [95% CI, 0.96-2.91]; P=0.072). Conclusions Women affected with type B acute aortic dissection were older and had more intramural hematoma, a lower incidence of end-organ malperfusion, and higher in-hospital mortality than men. However, female sex was not associated with in-hospital mortality after multivariable adjustment.

Distal transradial artery access for vascular access intervention.

BACKGROUND: Vascular access intervention is a useful treatment method for maintaining arteriovenous fistula (AVF) in dialysis patients. The outflow vein is commonly used as the access site for vascular access intervention. In cases where it is difficult to puncture veins due to multiple lesions or poor AVF development, vascular access intervention is performed using the radial artery. However, it is difficult to perform a vascular access intervention with radial artery access to the AVF in the distal forearm. We reported the efficacy and safety of vascular access intervention with distal transradial artery access (dTRA). CASE SERIES: We have been conducting vascular access intervention with dTRA access since January 2019. We evaluated complications and procedure time for 12 cases of vascular access intervention with dTRA access performed from January to December 2019.The success rate of the procedure was 100% and no puncture hemorrhagic complication was observed in 12 cases performed at our institution. No radial artery occlusion was observed in 12 cases. The average fluoroscopy time was 11.5 min and the average contrast volume was 41 ml. CONCLUSION: dTRA for vascular access intervention has advantages over conventional radial artery access in terms of safety of the procedure and ease of hemostasis.

Serum uric acid level is associated with reperfusion ventricular arrhythmias in acute myocardial infarction.

BACKGROUND AND AIM: In the acute phase of acute myocardial infarction (AMI), reperfusion ventricular arrhythmias such as ventricular tachycardia and ventricular fibrillation (Reperfusion VT/VF) resulting from reperfusion injury are one of the causes of in-hospital death. Predicting Reperfusion VT/VF is clinically important. Previous studies have reported that oxidative stress is the cause of reperfusion injury and reperfusion arrhythmia. There are also reports that xanthine oxidase inhibitors have the effect of preventing reperfusion arrhythmia. We hypothesized that hyperuricemia is a risk factor for reperfusion arrhythmias in AMI. The aim of our study is to investigate whether serum uric acid is associated with Reperfusion VT/VF in acute myocardial infarction. METHOD: This is a single-center, retrospective cohort study. We enrolled 612 ST elevation myocardial infarction patients who underwent successful primary percutaneous coronary intervention (PCI). We divided patients into a high serum uric acid group (HUA group) and a low serum uric acid group (LUA group) with a cutoff value of 7.0 mg/dl, which is the standard value of serum uric acid. We compared the frequency of Reperfusion VT/VF in both groups. RESULT: There were 111 patients in the HUA group and 512 patients in the LUA group. Creatinine tended to be higher in the HUA group than in the LUA group. (1.12 ± 0.41 mg/dl VS 0.92 ± 1.10 mg/dl P = 0.06). The frequency of Reperfusion VT/VF was significantly higher in the HUA group than in the LUA group (17.1% VS 4.0% P < 0.001). CONCLUSION: Elevated serum uric acid is associated with higher frequency of reperfusion ventricular arrhythmia.

Impending rupture of abdominal aortic aneurysm due to apixaban use.

Direct oral anticoagulants (DOAC) are useful for preventing embolism and venous thrombosis in patients with atrial fibrillation. There are also reports that DOAC can dissolve existing intracardiac thrombus. Here, we report a case in which DOAC lysed a thrombus in an abdominal aortic aneurysm (AAA), resulting in impending rupture of the AAA. An 85-year-old woman was admitted to our hospital with a diagnosis of congestive heart failure. She has had atrial fibrillation and started taking DOAC. Computed tomography (CT) performed on admission revealed an AAA with a large amount of intraluminal thrombus (ILT). Fifty days after the start of DOAC, she visited our hospital with the chief complaint of severe abdominal pain. CT showed no enlargement of the AAA, but the ILT in the AAA had dissolved. She was diagnosed with an impending rupture of an AAA. She underwent emergency aortic replacement with a Y-shaped vascular prosthesis. When using DOAC in patients with aortic aneurysms with ILT, we need to be aware of the risk of the thrombus dissolving. .

Clinical Effect of Adaptive Servo-Ventilation on Left Atrial Pressure During Catheter Ablation in Sedated Patients With Atrial Fibrillation.

BACKGROUND: Sedation during pulmonary vein isolation (PVI) for atrial fibrillation often provokes a decline in left atrial (LA) pressure (LAP) under atmospheric pressure and increases the risk of systemic air embolisms. This study aimed to investigate the efficacy of adaptive servo-ventilation (ASV) on the LAP in sedated patients.Methods and Results:Fifty-one consecutive patients undergoing cryoballoon PVI were enrolled. All patients underwent sedation using propofol throughout the procedure. After the transseptal puncture and the insertion of a long sheath into the LA, the LAP was measured. Then, the ASV treatment was started, and the LAP was re-measured. The LAP before and after the ASV support was investigated. Before ASV, the LAP during the inspiratory phase was significantly smaller than that during the expiratory phase (4.9±5.4 mmHg vs. 14.0±5.2 mmHg, P<0.01). The lowest LAP was -2.2±5.1 mmHg and was under 0 mmHg in 37 (73%) patients. After the ASV, the LAP during the inspiratory phase significantly increased to 8.9±4.1 mmHg (P<0.01), and lowest LAP increased to 4.7±5.9 mmHg (P<0.01). The negative lowest LAP value became positive in 30/37 (81%) patients. There were no statistical differences regarding obstructive sleep apnea (OSA), obesity, gender, or other comorbidities between patients with and without a negative lowest LAP after ASV support. CONCLUSIONS: ASV is effective for increasing the LAP above 0 mmHg and might prevent air embolisms during PVI.

Risk analysis for early mortality in emergency acute type A aortic dissection surgery: experience of Tokyo Acute Aortic Super-network.

OBJECTIVES: We investigated the various pre- and postoperative complications related to early (30-day) mortality after open surgery for acute type A aortic dissection. METHODS: Data from the Tokyo Acute Aortic Super-network database spanning January 2015 to December 2017 were retrospectively reviewed. Pre- and postoperative factors related to early postoperative mortality were assessed in 1504 of 2058 (73.0%) consecutive patients [age: 66.6 (SD: 13.5) years, male: 52.9%] who underwent acute type A aortic dissection repair. RESULTS: The early mortality rate following surgical repair was 8.9%. According to multivariable analysis, male sex [odds ratio (OR) 1.670, 95% confidence interval (CI) 1.063-2.624, P = 0.026], use of percutaneous circulatory assist devices (n = 116, 7.7%) including extracorporeal membrane oxygenators or intra-aortic balloon pumps (OR 4.857, 95% CI 2.867-8.228, P < 0.001), shock (n = 162, 10.8%) (OR 3.06, 95% CI 1.741-5.387, P < 0.001), cardiopulmonary arrest (n = 41, 2.7%) (OR 7.534, 95% CI 3.407-16.661, P < 0.001), coronary ischaemia (n = 36, 2.3%) (OR 2.583, 95% CI 1.042-6.404, P = 0.041) and cerebral ischaemia (n = 59, 3.9%) (OR 2.904, 95% CI 1.347-6.261, P = 0.007) were independent preoperative risk factors for early mortality, while cardiac tamponade (n = 34, 2.3%) (OR 10.282, 95% CI 4.640-22.785, P < 0.001), cerebral ischaemia (n = 80, 5.3%) (OR 2.409, 95% CI 1.179-4.923, P = 0.016) and mesenteric ischaemia (n = 15, 1.0%) (OR 44.763, 95% CI 13.027-153.808, P < 0.001) were independent postoperative risk factors. CONCLUSIONS: Not only critical preoperative conditions but also postoperative cardiac tamponade and vital organ ischaemia are risk factors for early mortality after acute type A aortic dissection repair.

Clinical significance of early systolic reverse flow in left anterior descending coronary artery on transthoracic echocardiography in patients with acute myocardial infarction.

BACKGROUND: Predicting the cardiac function in chronic phase of acute myocardial infarction (AMI) patients is important. Previous studies showed that the presence of early systolic reverse flow (ESRF) in coronary flow measured with a Doppler guide wire is a predictor of worsening chronic phase function in patients with anterior AMI. We routinely examined the coronary flow velocity (CFV) of the distal left anterior descending artery (LAD) using transthoracic echocardiography (TTE) in AMI patients. The aim of this study is to investigate whether the ESRF in TTE is associated with the chronic cardiac function, recovery of cardiac function, and the incidence of major adverse cardiac events (MACE) in patients with anterior AMI. METHODS: We enrolled 84 patients with their first anterior AMI. Using TTE, we recorded the CFV of distal LAD within 5 days after primary percutaneous coronary intervention. Patients were divided into two groups, ESRF + group (ESRF was detected in TTE: 21 cases) and ESRF- group (ESRF was not detected in TTE: 63 cases). We compared chronic cardiac function in TTE, changes in cardiac function in acute and chronic phase (ΔLVEF, ΔLVDd), and the incidence of MACE. RESULTS: The incidence of MACE in ESRF-group was lower than that in ESRF + group (3.3% vs 19.1% P = .02). LVEF in chronic phase in ESRF- group was higher than that in ESRF + group (54.1 ± 5.6% vs 40.4 ± 6.2% P < .001). ΔLVDd was smaller in ESRF-group than ESRF + group (-0.62 ± 4.0 mm vs +5.06 ± 3.4 mm P = .003). CONCLUSION: Early systolic reverse flow in TTE is a predictor of chronic cardiac function and incidence of MACE in patients with anterior AMI.

Usefulness of buddy-wire anchoring technique in cases where deep insertion of guide extension catheter is difficult.

Guide extension catheters are useful in PCI procedures when device passage is difficult. However, in complex lesions, such as severely tortuous vessels, deep insertion of the guide extension catheter cannot always be achieved even when balloon anchoring technique is applied. In such cases, in our hospital, a guidewire is added as a buddy wire and the balloon anchoring technique is applied. The advantage of this method is that the anchoring force is strengthened by anchoring another wire with the wire. By pulling the wire that has been anchored with a balloon, anchoring force is fortified, enabling deep insertion of the guide extension catheter and subsequent stent delivery. This method, which we refer to as the Buddy-wire anchoring technique, can be useful in cases of complex lesions, especially those with severely tortuous vessels, where device passage is difficult. Here we report on the Buddy-wire anchoring technique (Fig. 1). Fig. 1 a Cine image showing Buddy-wire anchoring technique. The black arrow indicated the tip of the guide extension catheter. The red arrow indicated the balloon which anchoring the wire. b Schema showing Buddy-wire anchoring technique.

Efficacy of Long Inflation Balloon Angioplasty for Acute Myocardial Infarction Due to Thrombotic Lesions.

BACKGROUND: Distal embolism is a frequent complication in percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) due to thrombotic lesions. Distal embolism causes no reflow phenomenon, which leads to worse patient prognosis after AMI. There is no established treatment to prevent distal embolism in PCI for thrombotic lesions. The aim of this study is to investigate the usefulness of long inflation balloon angioplasty (LIBA) with perfusion balloon in PCI for AMI due to thrombotic lesions. METHODS AND RESULTS: This is a case series study. We investigated 10 cases treated with LIBA for cases with massive thrombus remaining after thrombus aspiration therapy in primary PCI for acute myocardial infarction. We investigated the success rate of the procedure, residual stenosis rate, TIMI flow grade, TIMI frame count, and myocardial blush score in 10 cases of primary PCI with LIBA at our hospital. In all 10 cases, distal embolism was not observed by angiogram after LIBA. In 9 cases, residual stenosis was improved to less than 25% and the procedure was completed without a stent. Before PCI, all cases had TIMI flow grade 0, but in all 10 cases, TIMI flow grade 3 was obtained after PCI. The mean TIMI frame count was 19.6 ± 2.50 for RCA lesions and 27.5 ± 1.5 for LAD lesions. Regarding myocardial blush score, grade 3 was obtained in 8 cases and grade 2 was obtained in 2 cases. CONCLUSION: LIBA using a perfusion balloon is a useful technique in thrombus lesion to prevent distal embolism.

Clinical features of ST-segment elevation myocardial infarction in patients receiving welfare public assistance in urban area of Japan.

BACKGROUND: An increase in the rate of relative poverty and the number of welfare recipients is a serious social problem in Japan. A recent overseas survey demonstrated that lack of health insurance was associated with increased in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study is to investigate the clinical features of STEMI patients who receive welfare public assistance in Japan. METHODS: We enrolled 525 STEMI patients who were hospitalized in our hospital from 2010 to 2019. We divided patients into groups of patients receiving welfare public assistance (WPA group, N = 67) and groups of patients not receiving welfare public assistance (non-WPA group, N = 458). Patient characteristics, clinical outcome, and cardiac function on transthoracic echocardiography were compared. RESULTS: WPA group were younger than non-WPA group (61.2 ± 10.9 years VS 64.5 ± 13.3 years, p = 0.03). The prevalence of smoking was higher in WPA group compared to non-WPA group (91.0% VS 81.1% p = 0.04) and high-density lipoprotein cholesterol value of WPA group was lower than in non-WPA group (43.2 ± 9.9 mg/dl vs 47.1 ± 12.8 mg/dl, p = 0.005). Ventricular arrhythmia on admission was significantly more frequent in WPA group (11.9% VS 4.8%, p = 0.02). In acute and chronic phase, left ventricular ejection fraction in WPA group was lower than non-WPA group (in acute phase 46.6 ± 10.7% vs 53.3 ± 8.6% p = 0.001, in chronic phase 48.7 ± 10.1% vs 55.3 ± 9.4%, p = 0.008). CONCLUSION: STEMI patients receiving welfare public assistance had poorer control of coronary risk, increased risk of fatal arrhythmia, and reduced systolic function than those not receiving welfare public assistance. It is necessary to have a system that can strengthen lifestyle management, such as diet and smoking cessation for the purpose of improving the prognosis of welfare recipients after AMI.

Is systolic blood pressure high in patients with acute aortic dissection on first medical contact before hospital transfer?

Acute aortic dissection (AAD) cases are thought to have high blood pressure (BP) on admission; however, little data are available on BP prior to admission. The purpose of this study was to investigate systolic blood pressure (SBP) very early after symptom onset and before hospital transfer in patients with AAD to determine whether SBPs were high, and also whether SBPs were higher or lower compared with SBPs at hospital admission. We obtained results using three-year data derived from the Tokyo Acute Aortic Super Network Database. First, we selected 830 patients with AAD for which the "duration from symptom onset to first medical contact by ambulance crews" (SO-FMC) was within 60 min. We examined the SBPs of such patients. Next, we selected 222 patients with AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, and compared SBPs at FMC with those at hospital admission. Among types A (n = 190) and B (n = 117), in patients with an SO-FMC ≤ 15 min, the median SBP was 100 mmHg and 178 mmHg (p < 0.001), respectively; 9% and 50% (p < 0.001) of such patients, respectively, exhibited an SBP ≥ 180 mmHg; and 43% and 10% (p < 0.001) of such patients, respectively, had an SBP < 90 mmHg. Of patients with types A (n = 124) and B (n = 98) AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, SBPs at FMC were higher than those at hospital admission for the SBP ≥ 180 mmHg subgroups of both type A (194 mmHg vs. 159 mmHg, p < 0.001) and type B (199 mmHg vs. 186 mmHg, p < 0.001). Approximately 10 min after symptom onset and before hospital transfer, the measured SBPs of many patients with type A AAD were not necessarily high. However, the SBPs of cases with type B AAD were high as previously reported for SBP on admission. In addition, for the subgroup of SBP ≥ 180 mmHg at FMC within 15 min after symptom onset, SBPs at FMC were significantly higher than those at hospital admission for both types A and B; the higher SBP at symptom onset may have been partially associated with being a trigger of AD.

Complete His-ventricular block, atrial flutter and ventricular tachycardia as arrhythmogenic activities in a patient with takotsubo cardiomyopathy.

An association of atrial arrhythmias with takotsubo cardiomyopathy (TTC) has not been described previously. Here we report a 65-year-old male patient with TTC. The sudden appearance of atrioventricular block and subsequent bradycardia are believed to be key contributing factors for the development of TTC. Both ventricular tachyarrhythmia and various atrial arrhythmias, such as atrial flutter and atrial fibrillation, were observed during the initial management of the patient's TTC. We speculate that both the left ventricular contractile dysfunction and the arrhythmogenic activities may share a common underlying etiology in advanced heart failure patients with TTC. .