Comparison of Subsequent Inframalleolar Bypass Surgery and Repeat Endovascular Therapy for Infrapopliteal Restenosis in Patients With Chronic Limb-Threatening Ischemia Undergoing Primary Endovascular Therapy.

PURPOSE: Although endovascular therapy (EVT) is considered a vital strategy for treating infrapopliteal lesions in chronic limb-threatening ischemia (CLTI), the recurrence rate after EVT exceeds that after bypass surgery (BSX). The optimal approach for managing infrapopliteal lesion recurrence in patients with CLTI and unhealed ulcers remains uncertain. This study aimed to evaluate the clinical outcomes of repeat EVT and subsequent inframalleolar BSX for CLTI with infrapopliteal lesion recurrence. MATERIALS AND METHODS: We conducted a retrospective analysis of 140 patients with CLTI (mean age, 70±10 years; male, 71.4%; diabetes mellitus, 73.6%; dialysis, 74.3%; Rutherford 5, 79.3%; and Rutherford 6, 20.7%) who had an unhealed wound due to the recurrence of infrapopliteal lesions between January 2015 and May 2020. We compared the clinical outcomes of 40 patients who underwent the subsequent inframalleolar BSX with those of 100 patients who underwent repeat EVT. The outcome measures were amputation-free survival (AFS) and wound healing rate. Propensity score matching analysis was conducted to minimize differences in baseline characteristics. RESULTS: Propensity score matching extracted 38 pairs (38 patients in the subsequent BSX group and 83 patients in the repeat EVT group). AFS was not significantly different between the repeat EVT and subsequent BSX groups (81.9% vs 82.6% at 1 year, p=0.97). Neither was cumulative wound healing (42.8% vs 43.3% at 1 year, p=0.55). No baseline characteristics had any significant interaction effect on the association between repeat EVT, subsequent BSX, and failure of AFS. CONCLUSION: This study using propensity score matching revealed that the clinical outcomes following repeat EVT were comparable with those following subsequent inframalleolar BSX, indicating that repeat EVT may be a viable treatment option for CLTI with infrapopliteal lesion recurrence. CLINICAL IMPACT: Although endovascular therapy (EVT) has expanded the treatment options for chronic limb-threatening ischemia (CLTI), the recurrence rate after EVT is higher than that after bypass surgery (BSX). This retrospective study compared the clinical outcomes of repeat EVT with those of subsequent BSX for CLTI with infrapopliteal lesion recurrence. After propensity score matching, amputation-free survival (AFS) was not significantly different between the repeat EVT and subsequent BSX groups (81.9% vs 82.6% at 1 year, p=0.97). Neither was cumulative wound healing (42.8% vs 43.3% at 1 year, p=0.55). There was no difference between the 2 revascularization strategies when treating infrapopliteal restenosis lesions.

Outcomes of revascularization of stenotic inframalleolar lesions in chronic limb-threatening ischemia.

BACKGROUND: For chronic limb-threatening ischemia, revascularization has been reported for occlusions but not for stenosis in the inframalleolar (IM) lesions. We investigated the clinical outcomes of balloon dilation for stenotic IM lesions distal to the treatment target in the infrapopliteal (IP) legion. METHODS: We conducted a retrospective analysis of patients who had chronic limb-threatening ischemia and underwent revascularization of stenotic IM lesions distal to the target IP lesions between January 2015 and August 2022. The outcome measures were amputation-free survival, wound healing rate, and freedom from target IM reintervention. RESULTS: The 87 patients had a mean age of 72.7 ± 10.7 years and comprised 67.8% men, 74.7% with diabetes mellitus, 55.2% on dialysis, 33.3% who had Rutherford six classification. The amputation-free survival (AFS), wound healing, and freedom from target IM reintervention rates at 1 year were 82.9%, 53.3%, and 58.4%, respectively. On Cox proportional multivariate analysis, the predictors were Wound, Ischemia, and foot Infection (WIfI) ≥3 and diffuse stenosis in the target IM vessels for delayed wound healing and Global Limb Anatomic Staging System stage Ⅲ and ≥3 diseased IM vessels before endovascular therapy for target IM reintervention. At the time of reintervention, the lesion morphology had progressed from stenosis to occlusion in 50% of cases. CONCLUSIONS: In patients with chronic limb-threatening ischemia, revascularization of stenosis in IM lesions showed a high reintervention rate and progression of lesion morphology, although AFS and wound-healing rates were acceptable.

Bipolar radiofrequency ablation for re-entrant ventricular tachycardia of right bundle branch block and left bundle branch block morphologies with the common slow conduction zone at the left ventricular summit: a case report.

Background: The left ventricular (LV) summit has anatomical limitations, so the detailed mapping is difficult. Therefore, the mechanism of ventricular tachycardia (VT) originating from the LV summit is not well understood. Case summary: A 70-year-old man had VTs with right bundle branch block (VT1 and VT3) and left bundle branch block (VT2) morphologies originating from the left ventricular summit (LV summit). During the VT2 and VT3, fragmented potentials, which occurred earlier than the QRS onset, were recorded from bipolar electrodes of a catheter at the anterior intraventricular vein (AIV). By pacing from right ventricular apex, constant and progressive fusion were observed. During the entrainment pacing, the fragmented potentials in the AIV catheter were activated orthodromically and those in the His bundle were activated antidromically. In addition, there were two components of the ventricular electrogram at the LV summit area with the interval of more than 100 ms during the VTs. We performed bipolar radiofrequency ablation between the LV endocardium and AIV, and the VTs became non-inducible. Discussion: Non-sustained VT/premature ventricular contraction originating from LV summit is generally considered to occur due to abnormal automaticity or triggered activity. In contrast, using entrainment technique, we demonstrated that the VTs with multiple morphologies were sustained with a re-entrant mechanism. Fragmentated potentials recorded in the AIV catheter were activated orthodromically with the entrainment pacing, indicating the slowly conducting isthmus. The intramural VT substrate was also suggested with a prolonged conduction time between the two ventricular components during the VTs.

Improved outcomes of cardiac resynchronization therapy with a defibrillator in systolic heart failure: Analysis of the Japan cardiac device treatment registry database.

Background: Temporal change in outcomes of heart failure patients receiving cardiac resynchronization therapy with a defibrillator (CRT-D) is unknown. Methods: We assess outcomes and underlying heart diseases of patients receiving CRT-D with analyzing database of the Japan cardiac device treatment registry (JCDTR) at the implantation year 2011-2015 and New JCDTR at the implantation year 2018-2021. Results: Proportion of nonischemic heart diseases was about 70% in both the groups (JCDTR: 69%; New JCDTR: 72%). Cardiac sarcoidosis increased with the rate of 5% in the JCDTR to 9% in the New JCDTR group. During an average follow-up of 21 months, death from any cause occurred in 167 of 906 patients in the JCDTR group (18%) and 79 of 611 patients in the New JCDTR group (13%) (adjusted hazard ratio [aHR] in the New JCDTR group, 0.72; 95% confidence interval [CI]: 0.55-0.94; p = .017). The superiority was mainly driven by reduction in the risk of noncardiac death. With regard to appropriate and inappropriate implantable cardioverter-defibrillator (ICD) therapy, there was a significant reduction in the New JCDTR group versus the JCDTR group (aHR in the New JCDTR group, 0.76; 95% CI: 0.59-0.98; p = .032 for appropriate ICD therapy; aHR in the New JCDTR group, 0.24; 95% CI: 0.12-0.50; p < .0001 for inappropriate ICD therapy). Conclusions: All-cause mortality was reduced in CRT-D patients implanted during 2018-2021 compared to those during 2011-2015, with a significant reduction in noncardiac death.

Cardiac resynchronization therapy with a defibrillator in non-ischemic and ischemic patients for primary and secondary prevention of sudden cardiac death: Analysis of the Japan cardiac device treatment registry database.

Background: Panoramic studies in patients with cardiac resynchronization therapy with a defibrillator (CRT-D) focusing on the etiology and indication are scarce. Besides, a controversy exists regarding requirement of a defibrillator in non-ischemic patients for primary prevention with CRT. Methods: Annual trends of de novo CRT-D implantations from 2011 to 2020 and outcomes of those between January 2011 and August 2015 were analyzed from the Japan cardiac device treatment registry (JCDTR) and New JCDTR database. Results: From 2011 to 2020, 8062 CRT-D recipients were registered, whose dominant indication was primary prevention of sudden cardiac death with a steady rate of about 70%. There was no significant temporal change of the proportion of non-ischemic patients being about 70% and 65% for primary and secondary prevention, respectively. Non-ischemic patients for primary prevention were associated with increased odds of appropriate ICD therapy [adjusted hazard ratio (aHR): 1.66; 95% confidence interval (CI): 1.01-2.75; p = .047] and reduced odds of any death (aHR: 0.66; 95% CI: 0.44-0.99; p = .046) as compared to ischemic patients. Conclusions: Proportion of non-ischemic etiology was much higher than that of ischemic one in the CRT-D cohort. Based on the higher odds of appropriate ICD therapy, non-ischemic patients for primary prevention appear to be prudently selected in Japan.

Intravascular ultrasound findings of the protrusion of the EXOSEAL plug that caused acute limb ischemia.

Vascular closure devices have become popular for rapid hemostasis and early ambulation. However, there are a few reports of complications. We presented a case with acute limb ischemia caused by the protrusion of the EXOSEAL plug into the vessel. Intravascular ultrasound imaging helped determine the plug that caused the occlusion.

Successful Application of Stereotactic Body Radiation Therapy for Ventricular Tachycardia Substrate in a Patient With Nonischemic Cardiomyopathy.

Cardiac stereotactic body radiotherapy (SBRT) has been gaining attention as a potential treatment for patients with ventricular tachycardia (VT). Here, we describe a nonischemic patient with severe heart failure and VTs originating from the deep anteroseptal substrate that was refractory to standard and bipolar catheter ablations, and was successfully managed with SBRT. In conclusion, anteroseptal VTs resistant to catheter ablation in severe nonischemic heart failure might be an indication for cardiac SBRT as palliative therapy.

Predictors of cardiovascular mortality after an electrical storm in patients with structural heart disease.

BACKGROUND: Electrical storms (ESs) in patients with structural heart disease (SHD) have been reported to be associated with a poor prognosis. However, the detailed cause of death and influence of implantable cardioverter defibrillator (ICD) therapy in ES patients have not been fully investigated. Therefore, we sought to explore the detailed clinical course after an ES and the impact of the ICD therapy in patients with SHDs. METHODS: We retrospectively analyzed 31 consecutive patients with ESs who had undergone an ICD implantation. ESs were defined as three or more ventricular arrhythmias within 24 h. RESULTS: During a mean follow up of 4.5 years, 13 patients died. Among them, cardiovascular death (CVD) was observed in 11/13 (85%), and the leading cause of the CVD was end-stage heart failure. A New York Heart Association class ≥III at the time of the ES occurrence (HR 6.51 95% CI 1.94-25.1, p = 0.003) and any shock therapy (HR 5.94 95% CI 1.06-112.2, p = 0.04) were associated with CVD. CONCLUSION: In the current single center study, the major cause of death in ES patients with SHDs was end-stage heart failure. Any shock therapy was associated with CVD. Arrhythmia management to avoid ICD shocks might reduce the mortality in ES patients.