A cost-effectiveness analysis of remote monitoring after pacemaker implantation for bradycardia in Japan.

BACKGROUND: Although remote monitoring (RM) after pacemaker implantation is common, its cost-effectiveness has not been fully investigated. Therefore, we assessed the cost-effectiveness of RM compared with conventional follow-up (CFU) in Japanese patients with pacemakers. METHODS: A Markov model was constructed to analyze costs and quality-adjusted life years after pacemaker implantation. The target population was Japanese patients implanted with a dual-chamber pacemaker for bradycardia. Transition probabilities (e.g. atrial fibrillation, stroke, and device trouble) were obtained from literature and expert sources. Additionally, stroke risk was determined according to anticoagulation and CHADS2 scores. We used a 10-year horizon with sensitivity analyses for significant variables. RESULTS: Compared to CFU, RM was more effective; however, it was also more expensive. When the range of the Japanese willingness-to-pay threshold was considered to be ¥5,000,000, RM was at least cost-neutral relative to the CFU in all elderly patients with pacemakers for bradycardia. The cost-effectiveness of RM relative to CFU could be higher for patients with high CHADS2 scores, especially in patients with a CHADS2 score ≥ 3. Scenario analyses changing the interval between visits to an in-office evaluation in the CFU also demonstrated the same conclusions. In particular, when the interval between office visits was 1 year for the CFU, the RM could be more cost-effective. CONCLUSIONS: This study demonstrated that RM can be a cost-effective option for Japanese patients, especially those with high CHADS2 scores and long-term intervals between office visits.

Are Non-Invasive Modalities for the Assessment of Atherosclerosis Useful for Heart Failure Predictions?

Heart failure (HF) is becoming an increasingly common issue worldwide and is associated with significant morbidity and mortality, making its prevention an important clinical goal. The criteria evaluated using non-invasive modalities such as coronary artery calcification, the ankle-brachial index, and carotid intima-media thickness have been proven to be effective in determining the relative risk of atherosclerotic cardiovascular disease. Notably, risk assessments using these modalities have been proven to be superior to the traditional risk predictors of cardiovascular disease. However, the ability to assess HF risk has not yet been well-established. In this review, we describe the clinical significance of such non-invasive modalities of atherosclerosis assessments and examine their ability to assess HF risk. The predictive value could be influenced by the left ventricular ejection fraction. Specifically, when the ejection fraction is reduced, its predictive value increases because this condition is potentially a result of coronary artery disease. In contrast, using these measures to predict HF with a preserved ejection fraction may be difficult because it is a heterogeneous condition. To overcome this issue, further research, especially on HF with a preserved ejection fraction, is required.

Quantitative Assessment Using the Compartment Model for Detecting Regional Coronary Artery Disease by Dynamic Myocardial Perfusion Single-Photon Emission Computed Tomography.

BACKGROUND: This study aimed to quantitatively evaluate myocardial perfusion single-photon emission computed tomography (SPECT) using an original analysis tool in the compartment model for detecting regional significant coronary artery disease (CAD).Methods and Results: This study analyzed 41 patients (median age, 76 years) with suspected or known CAD who underwent both dynamic SPECT using 99 mTc-tetrofosmin and invasive coronary angiography. The quantitative analysis was performed using a single-tissue compartment model to evaluate the diagnostic performance of the myocardial flow reserve (MFR) for regional significant CAD, excluding infarcted territories. In the regional analysis, 114 vessels were assessed, of which 31 were diagnosed as significant coronary lesions (≥70% stenosis and/or fraction flow reserve ≤0.8). The MFR of regional significant CAD was significantly lower than that of non-significant CAD (1.11 [0.97-1.31] vs. 1.74 [1.30-2.27]; P<0.001). In the receiver operating characteristic curve analysis, the MFR displayed an area under the curve (AUC) of 0.81. While analyzing each coronary artery territory, the diagnostic performance of the MFR value in the left anterior descending (LAD) artery territory was found to be significantly higher than that found in qualitative assessment (AUC: 0.84 vs. 0.61). CONCLUSIONS: A quantitative analysis of dynamic SPECT data facilitated detecting regional CAD. For the LAD artery, the MFR displayed a higher diagnostic performance than the qualitative assessment of conventional myocardial perfusion SPECT.

Usefulness of cardiac fusion imaging with computed tomography and Doppler echocardiography in the assessment of conduit stenosis in complex adult congenital heart disease.

BACKGROUND: Noninvasive assessment of stenotic lesions in patients with complex adult congenital heart disease (ACHD) is challenging due to its complex morphology. The simultaneous two-screen display of multidetector-computed tomography (MDCT) and real-time echogram (STDME) technology can display a virtual multi-planar reconstruction from MDCT corresponding to the same cross-sectional image from transthoracic echocardiography (TTE). We investigated the usefulness of the STDME technology for stenosis severity assessment in complex ACHD patients. METHODS: Twenty-four complex ACHD patients with stenotic lesions were enrolled in this study. All patients underwent TTE and the STDME technology within a week after MDCT. Peak velocity and pressure gradient (PG) across the stenotic site were measured using continuous wave Doppler. Cardiac catheterization was performed in 17 patients. RESULTS: Nine out of the twenty-four patients had undergone repair with a conduit. Peak velocity and PG from the STDME technology were higher than those from TTE (peak velocity: 3.1 ± 1.1 vs. 2.8 ± 1.0 m/s; peak PG: 43 ± 28 vs. 34 ± 21 mmHg; both p < 0.01). Peak PG from the STDME technology showed significant correlations with those from catheterization in patients with a conduit (n=7) and those without a conduit (n=10) (r = 0.795 and 0.880, respectively; both p < 0.05), while peak PG from TTE was correlated with catheterization measurements only in patients without a conduit (r = 0.850, p < 0.05). CONCLUSIONS: The STDME technology enables more accurate assessment of conduit stenosis severity than does TTE in complex ACHD patients.

Potential benefit of a simultaneous, side-by-side display of contrast MDCT and echocardiography over routine sequential imaging for assessment of adult congenital heart disease: A preliminary study.

BACKGROUND: Management of adult congenital heart disease (ACHD) patients requires understanding of its complex morphology and functional features. An innovative imaging technique has been developed to display a virtual multi-planar reconstruction obtained from contrast-enhanced multidetector-computed tomography (MDCT) corresponding to the same cross-sectional image from transthoracic echocardiography (TTE). The aim of this study is to assess the usefulness of this imaging technology in ACHD patients. METHODS: This study consisted of 46 consecutive patients (30 women; mean age, 52±18 years old) with ACHD who had undergone contrast MDCT. All patients underwent TTE within a week of MDCT. An experienced sonographer who did not know the results of MDCT conducted a diagnosis using TTE and, then, using the new imaging technology. We studied whether this imaging technology provided additional or unexpected findings or makes more accurate diagnosis. RESULTS: In this imaging technology, MDCT cross-section provides higher-resolution image to the deep compared to corresponding TTE image. Depending on the MDCT section which can be arbitrarily set under the echo guide, we can diagnose unexpected or incremental lesions or more accurately assess the severity of the lesion in 27 patients (59%) compared to TTE study alone. This imaging technology was useful in the following situations: CONCLUSIONS: This integrated imaging technology provides incremental role over TTE in complex anatomy, and allows functional information in ACHD patients.

Assessment of Second- and Third-Generation Drug-Eluting Stents on Chronic Coronary Angioscopy　- Multicenter Study on Intra-Coronary AngioScopy After Stent (MICASA) Prospective Data Analysis.

BACKGROUND: The vascular response, in terms of quality and quantity, of the second- and third-generation drug-eluting stents (2G- and 3G-DES, respectively) was assessed prospectively on coronary angioscopy (CAS).Methods and Results:The Multicenter study on Intra-Coronary AngioScopy After Stent (MICASA) is a multicenter CAS registry. A total of 107 DES (71 2G- and 36 3G-DES) were prospectively observed on CAS 8.7±2.7 months after percutaneous coronary intervention. Neointimal coverage (NC) grade was evaluated using a 4-point grading scale, from 0 (no coverage) to 3 (complete coverage). Plaque yellow color (YC) was also assessed using a 4-point grading system, from 0 (white) to 3 (bright yellow). Max-NC (2G-DES vs. 3G-DES: 2.14±0.68 vs. 2.44±0.73, P=0.023); min-NC (1.07±0.48 vs. 1.39±0.60, P=0.002), and dominant-NC (1.57±0.69 vs. 2.08±0.84, P=0.002) were significantly higher and the YC grade (1.23±0.82 vs. 0.86±0.76, P=0.031) significantly lower in the 3G-DES group than in the 2G-DES group. There was no significant difference in the presence of thrombus (28.2% vs. 22.2%, P=0.51) between the 2G- and 3G-DES groups. CONCLUSIONS: The higher NC grade and lower YC grade in 3G-DES than in 2G-DES might be associated with better long-term clinical outcome, which remains to be determined in future studies.

Assessment of Arterial Stiffness Using the Cardio-Ankle Vascular Index.

BACKGROUND: Arterial stiffness is an independent predictor of outcomes for patients with cardiovascular disease. Although measurement of pulse wave velocity is a widely accepted, noninvasive approach for the assessment of arterial stiffness, its accuracy is affected by changes in blood pressure. SUMMARY: The cardio-ankle vascular index (CAVI) is an index of the overall stiffness of the artery from the origin of the aorta to the ankle and is theoretically independent of blood pressure at the time of measurement. CAVI increases linearly with age and is elevated even in mild arteriosclerotic disease. It can identify differences in the degree of arteriosclerosis among patients with severe arteriosclerotic disease and better reflects the severity of disease of the coronary artery than does brachial-ankle pulse wave velocity. Patients with higher CAVI values show a poor prognosis compared with those with lower CAVI values. Furthermore, CAVI can be lowered by controlling diabetes mellitus and hypertension. KEY MESSAGES: The primary aims of assessing arterial stiffness using CAVI are to assist in the early detection of arteriosclerosis, allowing timely treatment and lifestyle modification, and to quantitatively evaluate the progression of disease and the effectiveness of treatment. Whether CAVI-guided therapy can improve prognosis in high-risk patients needs to be further examined to confirm the clinical usefulness of this measure.

Comprehensive assessment of morphology and severity of atrial septal defects in adults by CT.

BACKGROUND: Cardiac CT is an excellent tool for evaluating the anatomy of a secundum atrial septal defect (ASD). However, a comprehensive assessment of its usefulness, including measurement of the pulmonary to systemic blood flow ratio in secundum ASD patients, has not been performed. OBJECTIVE: Therefore, this study was designed to evaluate the usefulness of CT for assessing the hemodynamics of secundum ASD in adults compared with transesophageal echocardiography (TEE), transthoracic echocardiography, and invasive catheterization. METHODS: Fifty adult patients with secundum ASD were enrolled. Cardiac CT scans (128-slice multidetector CT instrument) were acquired. These were followed by 2-dimensional reconstruction of the secundum ASDs to determine the defect size, the rim length between the outer edge of the defect, and the pulmonary to systemic blood flow (Qp/Qs) ratio. RESULTS: The maximum sizes of the secundum ASDs derived from CT and TEE studies were comparable (21.2 ± 8.0 vs. 20.0 ± 7.3 mm; P = .41; r = 0.960; P < .001). The rim lengths for the aortic, mitral, and tricuspid valves; the inferior vena cava; and posterior atrium were also comparable between CT and TEE measurements. The mean Qp/Qs ratio that was derived from CT measurements was comparable with that found by invasive catheterization (2.3 ± 0.7 vs. 2.3 ± 0.8; P = .73; r = 0.786; P < .001). CONCLUSION: Cardiac CT is feasible for assessing pathology and the severity of secundum ASD in adults.