Manual compression hemostasis using a hemostatic pad for the distal radial artery approach.

BACKGROUND: The method of hemostasis for the distal radial approach has not been standardized, although this approach has become increasingly popular due to its advantages. In this study, we investigated the feasibility of manual compression hemostasis using a calcium alginate pad after coronary angiography via the distal radial approach. METHODS: We retrospectively collected 150 consecutive patients (mean age, 74.9 ± 8.0 years; male, 75 %) who underwent coronary angiography via the distal radial artery with a predominantly 4 Fr sheath from April 2021 to December 2022 and were hemostatic according to the following methods. After sheath removal, hemostasis was achieved by manual compression for 10 min using a hemostatic pad containing calcium alginate. When hemostasis was confirmed, a small log-shaped gauze was placed over the pad and fixed using a self-adhesive elastic bandage for 2 h. All procedures were performed by four fellows just beginning the distal radial approach. RESULTS: The mean compression time was 12.4 ± 4.8 min, and hemostasis was successfully achieved in all patients, allowing the release of the elastic bandage after 2 h, with only one patient oozing the next morning. There were no major complications, while one patient had a >10 cm hematoma. Compared to that of the first 15 patients, for each fellow, the compression time of the subsequent patients was significantly shorter (14.5 ± 6.7 vs 11.1 ± 2.1 min, p < 0.01). CONCLUSIONS: Manual compression hemostasis using calcium alginate pads for the distal radial artery approach appears feasible with a simple learning.

A case of BNT162b2 COVID-19 vaccine-associated fulminant myocarditis in a very elderly woman.

Coronavirus disease 2019 (COVID-19) vaccination is reportedly safe and effective. The histologic features of post-COVID-19 vaccination myocarditis are unknown. We present a case of a 77-year-old Japanese woman diagnosed with eosinophilic myocarditis using endomyocardial biopsy, 7 days after the second dose of BNT162b2 COVID-19 vaccine. Steroid pulse therapy was effective.

Successful management of heart failure 45 years after surgical correction of tetralogy of Fallot.

A 59-year-old Japanese woman was admitted with heart failure due to severe pulmonary regurgitation and tricuspid regurgitation, in addition to atrial fibrillation 45 years after surgical correction of tetralogy of Fallot (TOF). She had been under treatment with medication and catheter ablation for arrhythmia including ventricular tachycardia for the past 28 years. She underwent pulmonary valve replacement as well as tricuspid and mitral valvuloplasty, which obviously improved her status even though her right ventricular end-diastolic volume index exceeded the recommended threshold. Patients who have undergone surgical correction of TOF need to be managed over the long term. .

Successful introduction of robotic-assisted percutaneous coronary intervention system into Japanese clinical practice: a first-year survey at single center.

In Japan, a robotic-assisted PCI (R-PCI) system, the CorPath GRX System (Corindus Inc.), has been approved for clinical use in 2018, which is the first introduction of R-PCI into Japan. In this study, the clinical performance of the R-PCI system in the initial year at Kurume University Hospital was evaluated comparing with conventional manual PCI (M-PCI). A total of 30 R-PCI and 77 M-PCI procedures performed between April 2019 and March 2020, were retrospectively included. The primary outcome was the rate of clinical success defined as < 30% residual stenosis without in-hospital major adverse cardiovascular events (MACE). The secondary outcomes were fluoroscopy time, dose area product (DAP), amount of radiation exposure to operators and assistants, procedural time, and contrast volume. Propensity-matching technique was used to match each R-PCI lesion to the nearest M-PCI lesion without replacement. After propensity score matching, 30 R-PCI procedures in 28 patients and 37 M-PCI procedures in 35 patients were analyzed. Clinical success rate with R-PCI was favorable and comparable to M-PCI (93.3 vs. 94.6%, p = 0.97), without any in-hospital MACE. The operator radiation exposure was significantly lower in R-PCI (0 vs. 24.5 µSV, p < 0.0001). Radiation exposure to the patients was tended to be reduced by R-PCI (DAP: 77.6 vs. 100.2 Gycm2, p = 0.07). There were no statistically significant differences in radiation exposure to the assistant, fluoroscopy time, procedural time and contrast volume between the two groups (radiation exposure to the assistant: 10.5 vs. 10.0 µSV, p = 0.64, fluoroscopy time: 27.5 vs. 30.1 min, p = 0.55, procedural time: 72.4 vs. 61.6 min, p = 0.23, and contrast volume: 93.2 vs. 102.0 ml, p = 0.36). R-PCI in selected patients demonstrated favorable clinical outcomes with dramatical reduction of radiation exposure to operators.

Serum interleukin-18 levels as a predictor for patients with genetic dysfunction of cytochrome P450 2C19 in dual antiplatelet therapy with clopidogrel.

BACKGROUND: P2Y12 reaction unit (PRU) is an index of platelet activity upon treatment with clopidogrel. In spite of suitable P2Y12 reactions in dual antiplatelet therapy (DAPT) with clopidogrel after percutaneous coronary intervention (PCI), cardiovascular events actually occur in some patients, possibly due to a genetic dysfunction of cytochrome P450 2C19 (CYP2C19), which is a major metabolic enzyme of clopidogrel. As testing the CYP2C19 phenotypes to predict such patients may lack general versatility in daily clinical practice, the aim of this study was to examine whether measuring the blood levels of some cytokines in patients showing desirable PRUs in DAPT with clopidogrel could be a substitute for testing the CYP2C19 phenotypes. METHODS: We analyzed relationships among PRU, serum levels of 51 cytokines, and CYP2C19 phenotypes in 22 patients receiving DAPT with aspirin and clopidogrel after PCI. RESULTS: Seventeen, 18, and 19 of 22 patients indicated PRU ≤ 208, PRU ≤ 230, and PRU ≤ 262, respectively. Approximately 60% of the patients had a genetically metabolic dysfunction of CYP2C19, and the serum levels of interleukin-18 were independently increased in those patients (p = 0.024 in patients with PRU ≤ 208, p = 0.021 with PRU ≤ 230, and p = 0.020 with PRU ≤ 262). The area under the curves in plot receiver operating characteristics curves for the serum levels of interleukin-18 were 0.94, 0.96, and 0.90 in the non-extensive metabolizer patients with PRU ≤ 208, PRU ≤ 230, and PRU ≤ 262, respectively. CONCLUSIONS: The serum levels of interleukin-18 may be a predictor to diagnose patients who receive undesirable DAPT with clopidogrel, possibly due to the genetic dysfunction of CYP2C19 in spite of suitable P2Y12 reactions after PCI.

Prasugrel effectively reduces the platelet reactivity units in patients with genetically metabolic dysfunction of cytochrome P450 2C19 who are treated with long-term dual antiplatelet therapy after undergoing drug-eluting stent implantation.

Dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitor is administered following percutaneous coronary intervention (PCI) with coronary stent implantation. Several studies have reported the effects of switching between P2Y12 inhibitors on platelet reactivity (P2Y12 reaction units: PRU), from acute to late phase after PCI. However, the effect of switching at very late phase is unknown. This study examined the effect on PRU in Japanese coronary heart disease patients with long-term DAPT (aspirin + clopidogrel) when switching from clopidogrel to prasugrel. Ninety-six patients were enrolled in this study. The median DAPT duration at enrollment was 1824.0 days. Twenty-three patients with PRU ≥ 208 at enrollment were randomly assigned into either continuing to receive clopidogrel (Continued Group; n = 11) or switching to prasugrel (Switched Group; n = 12). The primary endpoint was the rate of patients who achieved PRU < 208 at the end of 12 weeks of treatment, which was significantly higher in Switched Group relative to Continued Group (90.0% vs. 36.4%; P = 0.024). The secondary endpoint was the PRU at week 12 in groups subdivided according to cytochrome P450 (CYP) 2C19 genotypes. At week 12, extensive metabolizers (EM Group) had 202.3 ± 60.0 and 174.5 ± 22.3 in Continued Group and Switched Group (P = 0.591), respectively; intermediate and poor metabolizers (non-EM Group) had 229.4 ± 36.9 and 148.4 ± 48.4 in Continued Group and Switched Group (P = 0.002), respectively. The PRU for non-EM Group was significantly reduced in Switched Group. Thus, for patients with long-term DAPT (aspirin + clopidogrel) after PCI with coronary stent implantation, switching from clopidogrel to prasugrel resulted in a stable reduction in PRU, regardless of CYP2C19 polymorphism.

Low ankle brachial index predicts poor outcomes including target lesion revascularization during the long-term follow up after drug-eluting stent implantation for coronary artery disease.

BACKGROUND: Peripheral arterial disease (PAD) frequently coexists with coronary artery disease (CAD). The ankle-brachial index (ABI) is widely used for the screening for PAD. Low ABI is associated with short-term clinical outcomes in patients receiving coronary drug-eluting stent (DES) implantation. However, there is no report to examine the relationship between lower ABI and long-term clinical outcomes after DES implantation. Thus, we investigated the clinical long-term impact of low ABI after DES implantation. METHODS: This retrospective analysis included 181 CAD patients treated with DES from April 2010 to March 2013 in our institute. Based on ABI values, we divided the subjects into the low-ABI group　(ABI<0.9, n=29) and the normal ABI group　(0.9≤ABI<1.4, n=152). The incidence of target lesion revascularization (TLR), all-cause mortality, and major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of cardiac death, myocardial infarction, stroke, and any repeat revascularization, were compared between the 2 groups. RESULTS: During the median follow-up period of 43 months, the incidences of TLR, all-cause mortality, and MACCE were significantly higher in the low ABI group than in the normal ABI group (TLR: 41.4% vs 9.9%, p<0.001, all-cause mortality: 31.0% vs 3.9%, p<0.001, MACCE: 48.3% vs 11.2%, p<0.001, respectively). CONCLUSIONS: Low ABI may predict poor long-term outcomes, including TLR, in CAD patients treated with DES.

First Experience of Robotic-assisted Percutaneous Coronary Intervention in Japan.

In 2018, the CorPath GRX system (Corindus) was approved for use in Japan, marking the introduction of the first robotic-assisted system for percutaneous coronary intervention (PCI) in the country. The present report describes the first experience of robotic-assisted PCI for four coronary lesions in two cases in a single center. All procedures succeeded without any complications, although one procedure was converted to manual PCI by the operator's decision. Post-marketing surveillance to assess the impact of this novel system on both Japanese patients and physicians is currently ongoing in Japan.

Postural Orthostatic Tachycardia in a Patient with Type 2 Diabetes with Diabetic Neuropathy.

A 24-year-old Japanese man with type 2 diabetes mellitus and diabetic neuropathy was admitted to our ward to evaluate the cause of orthostatic intolerance. During a head-up tilt test, his heart rate increased from 105 to 155 beats/minute within 3 minutes, and chest discomfort began. He was diagnosed with postural orthostatic tachycardia syndrome (POTS), and orthostatic intolerance disappeared after ß-blocker treatment. Scintigraphy using 123I-metaiodobenzylguanidine showed decreased cardiac uptake. Power spectral analysis of heart rate variability for 24 hours in Holter electrocardiography demonstrated decreases in both sympathetic and parasympathetic nervous system activities, with a greater decrease in parasympathetic activity than sympathetic activity. The relative sympathetic hyperactivity in the present patient with diabetic neuropathy seemed to be related to POTS.

Pulmonary artery dysfunction in chronic thromboembolic pulmonary hypertension.

BACKGROUND: Unresolved thromboemboli in the pulmonary arteries (PA) is known to cause chronic thromboembolic pulmonary hypertension (CTEPH). However, it remains unknown if vascular dysfunction in pulmonary arteries exists in patients with CTEPH. METHODS AND RESULTS: We enrolled 7 female patients with CTEPH in this study, who have stable pulmonary hemodynamics after balloon pulmonary angioplasty (age; 73.6 ± 3.0 years old, mean right atrial pressure; 4.1 ± 0.4 mm Hg, mean pulmonary arterial pressure; 29.4 ± 2.7, mean pulmonary artery wedge pressure; 8.1 ± 1.2, pulmonary vascular resistance; 397.3 ± 51.7 dynes, cardiac index; 3.1 ± 0.2 L/min/m2). Pulmonary artery vascular function was evaluated by measuring pulmonary artery vasomotion in response to acetylcholine (Ach) at 10-month follow-up after balloon pulmonary angioplasty. All pulmonary vasoactive drugs were discontinued on the day of the procedures. The endothelium-dependent vasomotor response was evaluated by intra-pulmonary artery infusion of Ach at the dose of 10- 8 mol/l, and the vaso-spastic response was at 10- 6 mol/l. We evaluated vasomotor responses at the same segment in each patient, by measuring % changes of luminal area detected by quantitative pulmonary arterial optical frequency-domain imaging (OFDI), where OFDI catheter was fixed during the procedure. Endothelial dysfunction was observed at the dose of Ach at 10- 8 mol/l and vasoconstriction was also confirmed at the dose of Ach at 10- 6 mol/l in the diseased pulmonary arteries in CTEPH. CONCLUSIONS: These results indicated that the pulmonary artery dysfunction exists in patients with CTEPH, which may be involved in the pathogenesis and progression of CTEPH.

[Some problems for dosage form based on questionnaire surveying compliance in patients taking tamsulosin hydrochloride].

After the dosage form of tamsulosin hydrochloride was changed from a capsule to on orally disintegrating tablet (ODT, Harnal D), we often received patient complaints and noted an increase in noncompliance with medication regimens. The change in dosage form appeared to cause poor compliance by patients who had become accustomed to the light pink/white capsule over many years. Therefore, we carried out a questionnaire survey of patients taking the ODT form to determine the effects of changing the dosage form and the usefulness of the ODT. Most (92%) of respondents took the ODT with water. In addition, 16% missed taking the medicine after the change in dosage form. ODT is a dosage form that is easy to take for patient with dysphagia, or those on restricted water intake. However, it appears that elderly men and patients with visual disorders cannot distinguish the ODT from other medicines and this affects patient compliance. In conclusion, all pharmaceutical companies should consider the design of medications in terms of coloration, indications, or shape in anticipation of the aging society in future, so that patients can distinguish them. Furthermore, sufficient pharmaceutical care is needed to improve both compliance and safety management for the elderly.

Semi-micro column high-performance liquid chromatography with UV detection for quantification of aspirin and salicylic acid and its application to patients' sera administered with low-dose enteric-coated aspirin.

A simultaneous determination of aspirin (ASA) and its metabolite, salicylic acid (SA), in human serum by a semi-micro column HPLC-UV was developed. A relatively small size of serum sample (100 microL) containing ASA and SA was cleaned up by a simple solid phase extraction. A good separation of ASA and SA could be achieved within 25 min using a semi-micro ODS column with an eluent of MeOH/0.7 mm phosphoric acid solution (pH 2.5) = 50:50 (v/v). The calibration curves for ASA and SA showed good linearity (r = 0.999) with the detection limits 114 and 38 ng/mL at a signal-to-noise ratio of 3, respectively. ASA and SA in patients' sera administered with low-dose enteric-coated aspirin were determined, and the concentration ranges obtained for ASA and SA were 1.2-2.2 and 0.5-57.3 microg/mL, respectively.