Emergency and Prophylactic Extracorporeal Membrane Oxygenation for Patients Undergoing Valve-in-Valve Transcatheter Aortic Valve Implantation With Small Surgical Bioprosthesis: A Report of Four Cases.

Mechanical circulatory support (MCS) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely implemented as a rescue device in transcatheter aortic valve implantation (TAVI). Although prophylactic VA-ECMO (pECMO) in TAVI is preferable to emergency VA-ECMO (eECMO) in terms of overall survival, there is currently no consensus on the introduction criteria for pECMO. Here, we report four cases of eECMO and pECMO performed in valve-in-valve TAVI (ViV-TAVI) with a small surgical bioprosthesis to consider the validity of the current pECMO indications. In the two cases that were placed on eECMO, a 19 mm and 21 mm Carpentier-Edwards perimount bioprosthesis (CEP), a stented bioprosthetic valve, were sewn. After the transcatheter heart valve (THV) passed through the surgical aortic valve, acute aortic regurgitation developed, thus leading to hemodynamic instability requiring cardiopulmonary resuscitation, and therefore VA-ECMO was introduced. In the two cases using pECMO, 19 mm of CEP were sewn, and the THV was safely placed once MCS had been established. In all four cases, the patients were removed from VA-ECMO in the operating room following ViV-TAVI. The eECMO patients were discharged on postoperative days 12 and 20, while the pECMO patients were discharged on postoperative days 7 and 9, respectively. From our experience and based on the findings of some published reviews, ViV-TAVI with a small surgical bioprosthesis is considered to belong to a high-risk patient group demonstrating hemodynamic instability. The introduction of pECMO for such cases may therefore be an effective option for obtaining a better prognosis.

Manifold implications of obesity in ischemic heart disease among Japanese patients according to covariance structure analysis: Low reactivity of B-type natriuretic peptide as an intervening risk factor.

BACKGROUND/OBJECTIVES: Obesity is believed to be one of the major risk factors for cardiovascular disease in Western countries. However, the effects of obesity should be continuously examined in the Japanese population because the average bodily habitus differs among countries. In this study, we collectively examined the significance of obesity and obesity-triggered risk factors including the low reactivity of B-type natriuretic peptide (BNP), for ischemic heart disease (IHD) in Japanese patients. METHODS AND RESULTS: The study patients consisted of 1252 subjects (IHD: n = 970; non-IHD: n = 282). Multiple logistic regression analysis revealed that dyslipidemia, hypertension, diabetes, and the low reactivity of BNP were significant risk factors for IHD, but body mass index (BMI) was not. A theoretical path model was proposed by positioning BMI at the top of the hierarchical model. Exploratory factor analysis revealed that BMI did not play a causative role in IHD (P = NS). BMI was causatively linked to other risk factors (P<0.001 for hypertension; P<0.001 for dyslipidemia; P<0.001 for HbA1c; P<0.001 for LogBNP), and these factors played a causative role in IHD (P<0.001 for hypertension; P<0.001 for dyslipidemia; P<0.001 for HbA1c; P<0.001 for LogBNP). The intrinsic power of the low reactivity of BNP induced by high BMI on the promotion of IHD was fairly potent. CONCLUSION: This study demonstrated that obesity per se is not a strong risk factor for IHD in Japanese patients. However, several important risk factors triggered by obesity exhibited a causative role for IHD. The low reactivity of BNP is a substantial risk factor for IHD.

Long-term clinical and angiographic outcomes after sirolimus- and paclitaxel-eluting stent placement following rotablation for severely calcified lesions: a retrospective nonrandomized study.

We conducted a retrospective comparison of the long-term clinical and angiographic outcomes of 281 consecutive nonrandomized severely calcified lesions in 221 patients treated with a sirolimus-eluting stent (SES; CYPHER Bx VELOCITY) or a paclitaxel-eluting stent (PES; TAXUS Express) placed after rotablation between August 2004 and February 2009. The clinical safety endpoint, comprising the incidence of cardiac death, nonfatal recurrent myocardial infarction, and definite stent thrombosis, in 164 patients after exclusive SES placement (4.9 % with a mean clinical follow-up period of 1396 ± 763 days) was not significantly different from that after exclusive PES placement in 51 patients (2.0 %, 1011 ± 605 days; p = 0.364 and p < 0.001, respectively). The cumulative clinical safety endpoint-free ratio after exclusive SES placement was not significantly different from that after PES placement (p = 0.61, by log-rank test). The angiographic efficacy endpoint (binary restenosis: diameter stenosis >50 % at follow-up angiography) in the 169 lesions placed using SES (20.1 % with a mean angiographic follow-up period of 669 ± 605 days) was not significantly different from that in the 40 lesions using PES (17.5 %; 498 ± 320 days) (p = 0.707). In univariate analysis, SES use did not relate to the efficacy endpoint (p = 0.707). Thus, our small single-center study showed that the long-term clinical and angiographic outcomes after SES placements for severely calcified lesions after rotablation were not significantly different from those after PES placement.

Effects of Add-on Therapy Consisting of a Selective Mineralocorticoid Receptor Blocker on Arterial Stiffness in Patients with Uncontrolled Hypertension.

OBJECTIVE: Aldosterone plays an important role in the pathogenesis of atherosclerosis; however, the significance of mineralocorticoid receptor blockade for atherosclerosis has not been fully elucidated. In this study, the effect of add-on eplerenone on the degree of arterial stiffness was examined in patients with uncontrolled hypertension. METHODS: Forty-seven uncontrolled hypertensive patients who had previously been treated with anti-hypertensive drugs were examined retrospectively. Thirty-two patients received add-on therapy consisting of eplerenone (Group E) and 15 patients received add-on therapy with a Calcium channel blocker (CCB) or an increased dose of CCB (Group C) in addition to their baseline medications. Both the systolic blood pressure (SBP) and diastolic blood pressure (DBP) values were significantly decreased at two and 12 months in Group C. In contrast, neither the SBP nor DBP values were significantly changed at two months and eventually decreased at 12 months in Group E. The degree of arterial stiffness, as evaluated according to the cardio-ankle vascular index (CAVI), did not improve at either two or 12 months in Group C, whereas the CAVI values improved as early as at two months and the improvement was sustained at 12 months in Group E. The extent of change in the CAVI was not associated with the level of changes in the SBP or DBP values in Group E. CONCLUSION: Treatment with eplerenone added to the patient's baseline medications improves the degree of arterial stiffness as early as at two months after the beginning of treatment, independent of the blood pressure-lowering actions of these drugs in patients with uncontrolled hypertension.

Propensity-matched lesion-based comparison of midterm outcomes of TAXUS Express and TAXUS Liberté stents for de novo native coronary stenosis.

BACKGROUND: We examined the implication of the revised platform of TAXUS Liberté (TAXUS-Lib; Boston Scientific, Natick, MA, USA) from TAXUS Express (TAXUS-Exp; Boston Scientific) stents, after stent placements in a daily practice environment, on midterm clinical and angiographic outcomes. METHODS AND RESULTS: By adjusting historically different baselines with propensity score matching analysis in 1358 de novo native coronary stenoses, the incidence of the clinical safety endpoint (700-day cardiac death, nonfatal recurrent myocardial infarction, and definite stent thrombosis) after placement of TAXUS-Lib (0.60%; mean follow-up, 683±64 days) was not significantly different from that in the TAXUS-Exp group (1.20%; 677±96 days, p=0.182). Cardiac dysfunction (ejection fraction of left ventricle less than 40%) was the predictor of primary endpoint [odds ratio (OR), 17.8; 95% CI, 4.39-71.9; p<0.001]. In the baseline-adjusted angiographic followed-up lesions (n=443 in each arm), the incidence of secondary endpoint [binary in-stent restenosis: percent diameter stenosis (%DS) >50% at the follow-up angiography] in the TAXUS-Lib group (11.3%) was not significantly different from that in the TAXUS-Exp group (13.5%, p=0.368). TAXUS-Exp was not the predictor of secondary endpoint (OR, 1.20; 95% CI, 0.77-1.85; p=0.424). CONCLUSIONS: The midterm clinical and angiographic outcomes after placement of the new TAXUS-Lib stent for de novo coronary stenosis in a daily practice environment were statistically equivalent compared to the former TAXUS-Exp.