Comparative Data of Procedural and Midterm Outcomes in Patients Who Underwent Percutaneous Left Atrial Appendage Closure Between the WATCHMAN FLX and WATCHMAN 2.5 Devices　- Insight From the OCEAN-LAAC Registry.

BACKGROUND: Limited data are available regarding clinical outcomes after percutaneous left atrial appendage closure using WATCHMAN FLX (WM-FLX) and WATCHMAN-2.5 (WM2.5) devices in Asian patients.Methods and Results: Data of 1,464 consecutive patients (WM-FLX, n=909; WM2.5, n=555) were extracted from a Japanese multicenter registry, and clinical data were compared between the 2 groups. No in-hospital deaths, periprocedural stroke, or device embolization occurred. Procedural success was significantly higher in the WM-FLX than WM2.5 group (95.8% vs. 91.9%; P=0.002) owing to the lower incidence of periprocedural pericardial effusion (0.55% vs. 1.8%; P=0.021). No significant differences in all-cause death, postprocedural stroke, and device-related thrombus were observed between the 2 groups. However, the cumulative bleeding rate at 1 year was substantially lower in the WM-FLX group (7.8% vs. 16.4%; P<0.001). Landmark analysis of bleeding events highlighted lower bleeding rates in the WM-FLX than WM2.5 group within the first 6 months (6.4% vs. 14.8%; P<0.001), with comparable bleeding rates over the 6- to 12-month period (1.5% vs. 3.2%, respectively; P=0.065). CONCLUSIONS: This study demonstrated higher early safety and lower 1-year bleeding rates in the WM-FLX than WM2.5 group. The lower bleeding events with WM-FLX are likely due to multiple factors other than purely difference in devices, such as postprocedural drug regimen.

Inter-event and intra-event dynamics of microplastic emissions in an urban river during rainfall episodes.

Urban rivers represent the major conduits for land-sourced microplastics in the global oceans, yet the real-time dynamics of their emissions in rivers during rainfall (and runoff) events are poorly understood. Herein, we report the results of high-frequency sampling of microplastic particles (MPs) and fibers (MPFs) in the surface water of an urban river in Japan over the course of three rainfall events (i.e., light, moderate, and heavy rainfalls). The event mean concentrations (EMCs) of MPs amounted to 35,000 items/m3, 929,000 items/m3, and 331,000 items/m3; and the corresponding total loads were 0.5 kg, 19.8 kg, and 35.0 kg for light, moderate and heavy rainfalls, respectively. The inter-event total loads of MPs correlate well with the total rainfall, while the concentrations were linked with the number of antecedent dry days. The dynamic trends show that <2000 µm MPs displayed first flush effects during light to moderate rainfall events (>50% mass discharged with the initial 20-40% of flow). Small-sized MPs (10-40 µm) mobilized rapidly at lower rainfall intensities, whereas MPs over 2000 µm discharged immediately after the peak rainfall intensity. Moreover, <70 µm MPs depicted a surge following heavy rainfall events due to turbulent flow conditions reverting the deposited MPs into suspension. Overall, the three events increased the loads by 4-110 folds, and EMCs by 10-350 folds compared to the concentrations during dry weather while portraying a significant impact on 300-1000 µm MPs. The dynamics of MPs were correlated with those of suspended solids in river water, and the characteristics were comparable to the same of road dust sampled in Japan. Although the dynamic trends between MPs and MPFs in river water were comparable, MPFs were relatively less impacted by rain, likely due to the intervention of separate sewer systems in the study area.

Quantifying annual microplastic emissions of an urban catchment: Surface runoff vs wastewater sources.

Urban clusters are recognized as hotspots of microplastic pollution, and the associated urban rivers convey microplastics into the global oceans. Despite this knowledge, the relative contributions of various sources to the annual microplastic emissions from urban catchments remain scarcely quantified. Here, we quantified microplastic emissions from a riverine urban catchment in Japan. The total microplastics (size range: 10-5000 µm) released from the catchment amounted to 269.1 tons/annum, of which 78.1% is contributed by surface runoff and other uncontrolled emissions (UCE), and 21.1% emerges from the regulated wastewater (controlled emissions; CE), implying that approximately one-fifth is intercepted and removed by the wastewater treatment plants (WWTPs). This further indicated higher microplastic pollution by unmanaged surface runoff compared to untreated wastewater. In the dry season, WWTPs contributed significantly to the reduction of total microplastic emissions (95%) compared to wet periods (8%). On an annual scale, the treated effluent occupies only 0.1% of the total microplastics released to the river network (212.4 tons/annum), while the remaining portion is dominated by UCE, i.e., primarily surface runoff emissions (98.9%), and trivially by the background microplastic inputs that are potentially derived through atmospheric depositions in dry days (1.0%). It was shown that moderate and heavy rainfall events which occur during 18% of the year (within the context of Japan), leading to 95% of the annual microplastic emissions, are crucial for pollution control of urban rivers. Furthermore, our study demonstrated that surface area-normalized microplastic emissions from an urban catchment (∼0.8 tons/km2/annum) is globally relevant, especially for planning microplastic interventions for developed cities.

Pilot-scale performance of gravity-driven ultra-high flux fabric membrane systems for removing small-sized microplastics in wastewater treatment plant effluents.

The ubiquitous nature and environmental impacts of microplastic particles and fibers demand effective solutions to remove such micropollutants from sizable point sources, including wastewater treatment plants and road runoff facilities. While advanced methods, e.g., microfiltration and ultrafiltration, have shown high removal efficiencies of small-sized microplastics (<150 µm), the low flux encountered in these systems implies high operation costs and makes them less effective in high-capacity wastewater facilities. The issue presents new opportunities for developing cheap high-flux membrane systems, deployable in low-to high-income economies, to remove small-sized microplastic and nanoplastics in wastewater. Here, we report on developing an ultra-high flux gravity-driven fabric membrane system, assessed through a laboratory-scale filtration and large-scale performance in an actual wastewater treatment plant (WWTP). The method followed a carefully designed water sampling, pre-treatment protocol, and analytical measurements involving Fourier transform infrared (FTIR) spectroscopy and laser direct infrared (LDIR) imaging. The result shows that the ultra-high flux (permeance = 550,000 L/m2h⋅bar) fabric membrane system can effectively remove small-sized microplastics (10-300 µm) in the secondary effluent of an actual WWTP at high efficiency greater than 96 %. The pilot system demonstrated a continuous treatment capacity of 300,000 L/day through a 1 m2 surface area disc, with steady removal rates of microplastics. These findings demonstrate the practical, cheap, and sustainable removal of small-sized microplastics in wastewater treatment plants, and their potential value for other large-scale point sources, e.g., stormwater treatment facilities.

Implication of amino acid metabolism and cell surface integrity for the thermotolerance mechanism in the thermally adapted acetic acid bacterium Acetobacter pasteurianus TH-3.

IMPORTANCE: Acetobacter pasteurianus, an industrial vinegar-producing strain, is suffered by fermentation stress such as fermentation heat and/or high concentrations of acetic acid. By an experimental evolution approach, we have obtained a stress-tolerant strain, exhibiting significantly increased growth and acetic acid fermentation ability at higher temperatures. In this study, we report that only the three gene mutations of ones accumulated during the adaptation process, ansP, dctD, and glnD, were sufficient to reproduce the increased thermotolerance of A. pasteurianus. These mutations resulted in cell envelope modification, including increased phospholipid and lipopolysaccharide synthesis, increased respiratory activity, and cell size reduction. The phenotypic changes may cooperatively work to make the adapted cell thermotolerant by enhancing cell surface integrity, nutrient or oxygen availability, and energy generation.

Multimodal image and spectral feature learning for efficient analysis of water-suspended particles.

We have developed a method to combine morphological and chemical information for the accurate identification of different particle types using optical measurement techniques that require no sample preparation. A combined holographic imaging and Raman spectroscopy setup is used to gather data from six different types of marine particles suspended in a large volume of seawater. Unsupervised feature learning is performed on the images and the spectral data using convolutional and single-layer autoencoders. The learned features are combined, where we demonstrate that non-linear dimensional reduction of the combined multimodal features can achieve a high clustering macro F1 score of 0.88, compared to a maximum of 0.61 when only image or spectral features are used. The method can be applied to long-term monitoring of particles in the ocean without the need for sample collection. In addition, it can be applied to data from different types of sensor measurements without significant modifications.

Prognostic impact of remote dielectric sensing value following TAVR.

Remote dielectric sensing (ReDS) system non-invasively quantifies pulmonary congestion. Re-admission following trans-catheter aortic valve replacement (TAVR) remains an unsolved matter. Residual pulmonary congestion is a strong risk factor of worse clinical outcomes in patients with heart failure. ReDS system may have a prognostic impact in patients undergoing TAVR. Patients who received TAVR and ReDS measurements during index hospitalization between 2021 and 2022 were included. The prognostic impact of ReDS value on the composite endpoint of death or re-admission following index discharge was investigated. Totally, 42 patients (median 84 years, 14 men) were included. Median ReDS value at index discharge was 27% (24%, 30%) and 10 patients had ReDS values > 30%. During a median of 316 (282, 354) days following index discharge, a higher ReDS value at baseline was independently associated with the incidence of composite endpoint with an adjusted hazard ratio of 1.32 (95% confidence interval between 1.10 and 1.58) with a calculated cutoff of 30%, which significantly stratified the cumulative incidence of the composite endpoint (78% in the high ReDS group [N = 10] and 36% in the normal ReDS group [N = 32], p = 0.002). ReDS technology may be a promising tool to predict future clinical outcomes following TAVR by quantifying residual pulmonary congestion. The clinical implication of ReDS-guided aggressive intervention following TAVR remains the next concern.

Association Between Remote Dielectric Sensing and Body Mass Index.

Remote dielectric sensing (ReDS) is a non-invasive, electromagnetic energy-based technology to quantify pulmonary congestion. However, the accuracy of ReDS values in patients with a variety of physiques has not been fully validated.Prospective successive measurements of ReDS values and body mass index (BMI) were performed on admission in consecutive hospitalized patients with cardiovascular diseases. Patients were stratified into 4 groups according to the WHO classification: underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 24.9), pre-obese (25.0 ≤ BMI < 29.9), and obese (30.0 ≤ BMI). The indexed ReDS value was defined as a ReDS value divided by the modified congestion score index (the severity of pulmonary congestion on chest X-ray). The indexed ReDS values were compared among the 4 stratified groups.A total of 436 patients (76 [69, 82] years old and 254 men) were included. The median indexed ReDS values were 21.3 (19.1, 23.8), 25.7 (21.0, 29.5), 25.7 (20.3, 31.0), and 28.0 (21.1, 34.0) in underweight, normal weight, pre-obese, and obese patients, respectively, highlighting the underweight group had the lowest values (P < 0.001).ReDS values may be underestimated and specific caution should be paid in its interpretation in underweight patients.

Seasonal effects, spatial distribution, and possible sources of microplastics in the Chao Phraya River estuary, Thailand.

Microplastics (MPs) in estuaries are sources of plastic debris that enter the marine environment. However, there is limited information on the seasonal effect on the accumulation of MPs in the estuaries of Thailand. The abundance and spatial distribution of MPs in the dry and wet seasons were investigated in the Chao Phraya River estuary, and possible emission sources were traced. Dominant factors affecting the distribution patterns of MPs have also been reported. All collected water samples contained MPs, with a mean abundance of 4.0 ± 2.8 × 105 particles/km2 in the wet season and 5.2 ± 3.3 × 105 particles/km2 in the dry season. Fragments were mostly observed, with polypropylene and polyethylene being the dominant polymers. The findings also showed that accumulation of MPs was directly influenced by the river discharge rate into the estuary. Further, the spatial distribution of MPs was closely related to seasonal variations in sea surface currents. Microplastic pollution status with seasonal variations and possible emission sources could provide important information to the government and local environmental organizations for MP pollution prevention and future MP studies in estuarine environments.

Occurrence and distribution of plastic particles (10-25,000 µm) and microfibers in the surface water of an urban river network in Japan.

Urban rivers remain the key conduits conveying land-sourced plastics into the ocean. However, detailed information is limited on the concurrent evaluation over a wide array of particle size-specific abundances, characteristics, and distribution patterns of plastics in riverine environments. Therefore, this study provides a comprehensive assessment of plastic pollution in an urban river network in Japan by analyzing mesoplastics (5000-25,000 µm), large microplastics (300-5000 µm), small microplastics (SMPs, 10-300 µm), and microplastic-fibers (MPFs, 10-5000 µm) concurrently, for the first time. Sampling was conducted at seven stations in the Kamo and Katsura Rivers flowing across metropolitan Kyoto City. The analytical procedures involved infrared spectroscopy and fluorescence-staining microscopy. The concentrations of plastics were moderate compared to the global reports and gradually increased along the river flow (3550-15,840 items/m3; 180-13,180 µg/m3), mostly due to urban discharges via non-point sources. The number concentrations increased with decreasing particle size, marking 99.94% of SMPs, including 50% smaller than 40 µm. Conversely, mass concentrations decreased, exhibiting 96% larger than 1000 µm (64% mesoplastics including 20% around 5000 µm), along with 2% SMPs. Polyethylene (PE) and polyvinyl alcohol were distinct among SMPs, with PE indicating higher susceptibility to fragmentation compared to polypropylene and other polymer types. MPF concentrations were homogeneous throughout the watershed (1470-3600 items/m3; 520-1060 µg/m3), with a higher proportion of fibers smaller than 1000 µm (86%), apparently originating from polyethylene terephthalate/nylon/acrylic-like textile fibers. The proportion of MPFs surpassed particles within 100-3000 µm and was considerably high around 300 µm (> 98%). The river network of Kyoto conveys billions of tiny microplastics to the Yodo River, the primary water resource downstream, within a dry day.

Therapeutic Strategy for Patients with Concomitant Pulmonary Artery Hypertension and Hypertrophic Obstructive Cardiomyopathy: A Rare Case Report.

Combined cases of hypertrophic obstructive cardiomyopathy (HOCM) and pulmonary arterial hypertension (PAH) are rare and have a management dilemma. Although preload is crucial in the management of HOCM, anti-PAH agents dramatically change the preload, leading to improving or worsening heart failure in patients with HOCM. We had a 74-year-old woman with Sjogren-syndrome-associated PAH. Her heart failure worsened following the initiation of anti-PAH agents due to an incremental preload on the left ventricle, whereas HOCM clinically developed following the termination of anti-PAH agents and progressing anorexia due to the progression of the left ventricular outflow obstruction. Careful monitoring of the left ventricular outflow obstruction during initiation/termination of anti-PAH agents and medical intervention to the HOCM are highly recommended.

Decoupling Between Pulmonary Artery Diastolic and Wedge Pressure Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Coexistent pulmonary hypertension with severe aortic stenosis confers a greater risk of mortality for patients undergoing transcatheter aortic valve replacement (TAVR). In this patient population, the impact of significant decoupling between pulmonary artery diastolic and pulmonary capillary wedge, as it relates to clinical risk, remained uncertain.Methods and Results:Patients with severe aortic stenosis who underwent TAVR and completed pre-procedural and post-procedural invasive hemodynamic assessments with right heart catheterization were retrospectively assessed. The impact of post-TAVR decoupling, defined as a pressure difference ≥3 mmHg, on 2-year all-cause mortality or risk of heart failure admission was analyzed. Among 77 included patients (median age 86 years, 23 men), 16 had post-TAVR decoupling. The existence of post-TAVR decoupling was associated with a higher cumulative incidence of the primary endpoint (44% vs. 7%, P=0.001), with an adjusted hazard ratio of 5.87 (95% confidence interval 1.58-21.9, P=0.008). CONCLUSIONS: A greater risk of worse outcomes in those with post-TAVR decoupling was observed. A therapeutic strategy for post-TAVR decoupling and its clinical implication need to be created and investigated in the future.

Assessment of microplastic contamination in the urban lower Chao Phraya River of Bangkok city, Thailand.

Rivers are one of the major pathways for the transportation of microplastics (MPs) from land-based sources to the ocean. However, there are only a few studies on MPs in freshwater environments, particularly in Asian countries. In this study, MP contamination in the Chao Phraya River in selected locations distributed throughout Bangkok, Thailand was investigated. MPs were collected using a Manta net with a mesh size of 335 µm. After digestion and distinction based on density, MPs were observed using a stereomicroscope, and polymer types were identified using Fourier Transform Infrared Spectroscopy. MP concentrations detected in the five sampling locations of the river water from upstream to downstream were 11, 35, 40, 15, and 4 particles/m3, with an average concentration of 21±16 particles/m3. Most MPs were identified as either fragments or sheets/films. Polypropylene was the dominant polymer type. The number of MPs increases as their size decreases. Potential sources of MPs may include the degradation of single-use plastic products, especially containers and plastic packaging. MP concentrations and characteristics varied for different locations, indicating different sources and pathways of MPs in urban contexts. Further investigation on the different pathways of the transportation of MPs to river water from land-based sources is required.

Transcatheter closure of patent foramen ovale accompanying right-to-left shunt during Impella support.

We experienced a 65-year-old woman who was diagnosed as fulminant myocarditis and transferred on mechanical ventilator and veno-arterial extracorporeal membrane oxygenation (ECMO) supports. Impella 5.0 support was additionally initiated to improve pulmonary edema and unload left ventricle. We found a patent foramen ovale (PFO) at the time of Impella insertion by transesophageal echocardiography. Follow-up transesophageal echocardiography found a development of right-to-left shunt flow through PFO accompanying central hypoxia during Impella P8 support. Veno-arterial ECMO was converted to veno-arterio-venous ECMO and PFO was occluded percutaneously on the next day, which stabilized hemodynamics and systemic oxygen supply. In case of Impella 5.0 support, the existence of PFO and the development of right-to-left shunt flow should be carefully surveyed and closed immediately to maintain hemodynamics and systemic oxygen supply.

Validation of Inter-Rater and Intra-Rater Reliability of Remote Dielectric Sensing Measurement.

Remote dielectric sensing (ReDS) is a recently introduced non-invasive electromagnetic-based device used to quantify lung fluid levels. Nevertheless, its inter-rater and intra-rater reliability remain uncertain. In 10 healthy volunteers, ReDS values were measured three times successively by the officially trained expert examiner to validate intra-rater reliability. Similar measures were performed by a total of three examiners to validate inter-rater reliability. Intra-class correlation (ICC) was applied to validate each reliability. Ten healthy volunteers [median 34 (32, 40) years old, 10 men, body mass index 23.0 (21.2, 23.9) ] were included. Median ReDS value was 28% (25%, 31%). For the intra-rater reliability, ICC (1, 1) and ICC (1, 3) were 0.966 and 0.988, respectively (P < 0.001). For the inter-rater reliability, ICC (2, 1) and ICC (2, 3) were 0.683 and 0.866, respectively (P < 0.001). Given almost perfect intra-rater reliability, an examiner does not need to repeat ReDS measurement. Given substantial inter-rater reliability, ReDS measurements had better be measured by multiple examiners if possible.

Remote Dielectric Sensing to Assess Residual Pulmonary Congestion Following Percutaneous Mitral Valve Repair.

Background and Objectives: Percutaneous mitral valve repair using a MitraClip system is an established therapeutic strategy to treat severe mitral regurgitation, which is recommended by guidelines in Europe and in the United States, whereas residual mitral regurgitation is associated with mortality and morbidity. Accurate assessment of residual mitral regurgitation is crucial for risk stratification and further adequate intervention, whereas its quantification has technical limitations due to "double" regurgitation that is often encountered following valve clipping. Remote dielectric sensing (ReDSTM) is a non-invasive electromagnetic-based technology to quantify lung fluid levels and might be a promising tool to assess the impact of residual mitral regurgitation following MitraClip. Materials and Methods: Following MitraClip, ReDS values measurements and right heart catheterization were performed and correlated. Results: We had 13 patients (median 74 years, 7 men) who underwent successful MitraClip. According to the visual estimation, eight patients had none or mild regurgitation, and five patients had moderate regurgitation. ReDS values were distributed widely between 16% and 33%, irrespective of the severity of regurgitation. ReDS values had a moderate correlation with invasively measured pulmonary artery wedge pressure (r = 0.73, p = 0.004). Conclusions: ReDS value might be a promising tool to assess residual pulmonary congestion following MitraClip, irrespective of the visually estimated severity of residual mitral regurgitation.

Change in Lung Fluid Volume during Exercise in Patients with Exercise-Induced Mitral Regurgitation.

Exercise-induced mitral regurgitation (MR) can be diagnosed during stress echocardiography testing. Remote dielectric sensing (ReDSTM) is a noninvasive electromagnetic-based modality to measure lung fluid levels. The change in lung fluid levels in patients with MR during stress echocardiography remains unknown. Patients with symptomatic MR at baseline and suspected worsening exercise-induced MR underwent stress echocardiography. ReDS values were measured before and after the tests. A total of four patients (ages ranging between 74 and 84 years old, three women) underwent stress echocardiography testing using a bicycle ergometer. In patient A, MR effective regurgitant orifice area (EROA) remained unchanged and ReDS values decreased. EROA increased significantly with a small incremental change in ReDS values in patient B and patient C, who underwent valve repair with MitraClip later. Patient D had a mild increase in MR EROA but a considerable increase in ReDS values (from 22% to 32%), and eventually received valve repair with MitraClip. The ReDS system may be a complementary tool to conventional stress echocardiography in the evaluation of clinically significant MR and considering mitral valve intervention.

Marked Impairment of Endothelium-Dependent Digital Vasodilatations in Patients With Microvascular Angina: Evidence for Systemic Small Artery Disease.

OBJECTIVE: It remains to be elucidated whether and how endothelial functions are impaired in peripheral circulation of patients with coronary functional disorders, such as vasospastic angina (VSA) and microvascular angina (MVA). We simultaneously examined endothelial functions of peripheral conduit and resistance arteries in patients with coronary functional disorders, with a special reference to NO and endothelium-dependent hyperpolarization factors. Approach and Results: Based on the results of invasive coronary acetylcholine testing and coronary physiological measurements, we divided 43 patients into 3 groups; VSA, MVA, and VSA+MVA. Endothelium-dependent vasodilatations of the brachial artery and fingertip arterioles to intra-arterial infusion of bradykinin were simultaneously evaluated by ultrasonography and peripheral arterial tonometry, respectively. To assess NO and endothelium-dependent hyperpolarization factors, measurements were repeated after oral aspirin and intra-arterial infusion of NG-monomethyl-L-arginine. Additionally, endothelium-independent vasodilatations to sublingual nitroglycerin and plasma levels of biomarkers for endothelial functions were measured. Surprisingly, digital vasodilatations to bradykinin were almost absent in patients with MVA alone and those with VSA+MVA compared with those with VSA alone. Mechanistically, both NO- and endothelium-dependent hyperpolarization-mediated digital vasodilatations were markedly impaired in patients with MVA alone. In contrast, endothelium-independent vasodilatations to nitroglycerin were comparable among the 3 groups. Plasma levels of soluble VCAM (vascular cell adhesion molecule)-1 were significantly higher in patients with MVA alone compared with those with VSA alone. CONCLUSIONS: These results provide the first evidence that both NO- and endothelium-dependent hyperpolarization-mediated digital vasodilatations are markedly impaired in MVA patients, suggesting that MVA is a cardiac manifestation of the systemic small artery disease.

Impact of optimal heart rate on left ventricular reverse remodeling and functional improvement in patients with systolic heart failure.

Heart rate modulation therapy using ivabradine reduces mortality and morbidity in patients with systolic heart failure, whereas too reduced heart rate seems to worsen the clinical outcome. The optimal heart rate during heart rate modulation therapy remains unknown. Consecutive patients with left ventricular ejection fraction < 50% who received echocardiographic assessments and simultaneous heart rate measurements were retrospectively investigated. Theoretically ideal heart rate was calculated using a previously proposed formula: 93 - 0.13 × (deceleration time [msec]). Impacts of heart rate on the 1-year echocardiographic left ventricular reverse remodeling were compared among the three groups stratified by the heart rate status: optimal heart rate group (within 10 bpm of ideal heart rate), below-optimal heart rate group (< 10 bpm of ideal heart rate), and above-optimal heart rate group (> 10 bpm of ideal heart rate). A total of 75 patients (70 years old, 60 men) were included. There were no significant differences in the baseline characteristics among the three groups, except for the higher prevalence of tolvaptan use and higher plasma B-type natriuretic peptide level in the below-optimal heart rate group. Left ventricular end-diastolic diameter (from 55 to 54) and left ventricular ejection fraction (from 39 to 46) improved significantly only in the optimal heart rate group at 1-year follow-up (p < 0.05 for both). Optimal heart rate, which was calculated using a formula consisting of deceleration time, was associated with cardiac reverse remodeling in patients with systolic heart failure. Prospective study to investigate the implication of deceleration time-guided aggressive heart rate optimization is the next concern.

The implication of optimal heart rate in patients with systolic dysfunction following TAVR.

Heart rate reduction therapy using ivabradine has demonstrated its prognostic implication in patients with heart failure with reduced ejection fraction. However, the target heart rate with optimal clinical outcomes, particularly for those with systolic dysfunction following a transcatheter aortic valve replacement (TAVR), remains unknown. Consecutive patients with left ventricular ejection fraction (LVEF) < 50% and sinus rhythm following TAVR received transthoracic echocardiography at index discharge. The ideal heart rate was calculated using a formula: 93 - 0.13 × (deceleration time [ms]). Those whose actual heart rates at discharge were within 10 bpm of the calculated ideal heart rate were assigned to the optimal heart rate group, and their prognosis was compared with those without. Twenty-four patients (83 [78, 85] years old, LVEF 41% [35%, 44%], 16 males) were included. The median difference between actual heart rate and ideal heart rate was 12 (0, 16) bpm and 11 patients were assigned to the optimal heart rate group. One year later, the optimal heart rate group achieved more improvement in LVEF (24% [15%, 28%] vs. 7% [7%, 12%], p = .003) and had lower heart failure readmission rates (0.059 vs. 0.116 events/year; p = .49). In conclusion, an optimal heart rate might be associated with cardiac reverse remodeling and prevention of heart failure recurrences in patients with systolic dysfunction following TAVR. The implication of deceleration time-guided heart rate optimization therapy for such cohorts remains the next concern.