A Prospective Randomized Controlled Clinical Study to Investigate the Efficacy and Safety of Hypoxia-Inducible Factor-Prolyl Hydroxylase Inhibitors in Non-Dialysis Patients with Chronic Heart Failure and Renal Anemia Switched from Continuous Erythropoietin Receptor Activator Treatment.

Background/Objectives: Chronic kidney disease (CKD) and anemia are independent prognostic factors for heart failure. In recent years, hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors have become available for the treatment of renal anemia. This prospective randomized controlled study aimed to investigate the effects of switching from a continuous erythropoietin receptor activator (CERA) to one of four HIF-PH inhibitors in patients with chronic heart failure and renal anemia. Methods: Forty patients were randomized by the envelop method to receive treatment with roxadustat, daprodustat, vadadustat, or molidustat. The primary endpoint was the change in the hemoglobin (Hb) level. Secondary endpoints included changes in erythropoietin, changes in free T3, free T4, and thyroid-stimulating hormone (TSH), adverse effects, and drug dose increases and decreases. This study was preregistered in the University Hospital Medical Information Network Clinical Trials Registry (study ID: UMIN000041651). Results: We found no statistically significant difference between Hb levels with HIF-PH inhibitors and CERA, but at month 6, the Hb level was significantly higher with roxadustat than with vadadustat and daprodustat. Erythropoietin decreased significantly after switching to HIF-PH inhibitors. HIF-PH inhibitors had various significant effects on free T3, free T4, and TSH. No adverse events occurred. The doses of some drugs had to be increased or decreased. Conclusions: In patients with heart failure and renal anemia receiving CERA, Hb, NT-ProBNP, and renal function were similar after switching from CERA to HIF-PH inhibitors. The individual HIF-PH inhibitors appear to have different effects on anemia and thyroid function. However, because this was a single-center study with a limited sample size, the efficacy and potential limitations of HIF-PH inhibitors need to be further clarified.

Single coronary artery with aortic valve replacement followed by aortic root replacement due to endocarditis: A case report.

A woman with a single coronary artery underwent aortic valve replacement due to aortic stenosis. Two years later, she developed an aortic annular abscess around the right coronary cusp and non-coronary cusp. Significant adhesions to the right coronary artery (RCA) resulted from the abscess, making artery separation challenging, and raising concerns about potential future RCA stenosis. The patient subsequently underwent aortic root replacement and coronary artery bypass grafting. Utilizing a freestyle valve and a saphenous vein graft for the RCA. Following the procedure, the patient was discharged and has remained symptom-free without any recurrence of infection for 2 years.

Delayed Giant Pseudoaneurysm With Left-to-Right Shunt Following Postinfarct Ventricular Septal Perforation Repair.

Left ventricular pseudoaneurysm with a left-to-right shunt is extremely rare, requiring surgery if symptomatic; however, surgery has a high risk. Here, the case of a 77-year-old man with heart failure symptoms is reported, in which he develops a giant left ventricular pseudoaneurysm 16 months after ventricular septal perforation repair as a result of acute myocardial infarction, with mild shunt blood flow from the pseudoaneurysm to the right ventricle. Intraoperative findings showed a free wall rupture along the area where the patch was secured during the initial surgery. The patient was discharged on postoperative day 13, and postoperative examination revealed no abnormalities.

A Comparative Study to Investigate the Effects of Bisoprolol in Patients with Chronic Heart Failure and Hypertension When Switched from Tablets to Transdermal Patches.

BACKGROUND: Oral beta-blockers are effective for heart failure and hypertension. Here, we conducted a prospective study to investigate the efficacy of the beta-blocker bisoprolol in patients switching from the oral tablet to the transdermal patch. METHODS: We studied 50 outpatients receiving oral bisoprolol for chronic heart failure and hypertension. After patients switched treatments, we measured heart rate (HR) over 24 h by Holter echocardiography as the primary endpoint. Secondary endpoints were (1) HR at 00:00, 06:00, 12:00, and 18:00, (2) the total number of premature atrial contractions (PACs) over 24 h and the incidence rate per time segment, and the total number of premature ventricular contractions (PVCs) over 24 h and the incidence rate per time segment, (3) blood pressure, (4) atrial natriuretic peptide and B-type natriuretic peptide, and (5) echocardiography. RESULTS: Minimum, maximum, mean, and total HR over 24 h was not significantly different between the two groups. Mean and maximum HR at 06:00, total PACs, total PVCs, and PVCs at 00:00 to 05:59 and 06:00 to 11:59 were significantly lower in the patch group. CONCLUSION: Compared with oral bisoprolol, the bisoprolol transdermal patch lowers HR at 06:00 and inhibits the onset of PVCs during sleep and in the morning.

A Single Arm Clinical Study on the Effects of Continuous Erythropoietin Receptor Activator Treatment in Non-Dialysis Patients with Chronic Heart Failure and Renal Anemia.

Erythropoiesis-stimulating agents improve the NYHA functional class and decrease the hospital readmission rates for heart failure; however, little is known about the influence of continuous erythropoietin receptor activator (CERA) on the heart. Therefore, a prospective study was conducted to investigate the effects of CERA on cardiac and renal function and oxidative stress in chronic heart failure with renal anemia. Sixty patients with chronic heart failure and renal anemia were enrolled and received CERA for 12 months. The primary endpoints were hemoglobin (Hb) and hematocrit, and the secondary endpoints were: (1) atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP); (2) NYHA class; (3) echocardiography; (4) blood urea nitrogen, creatinine, cystatin C, and urinary albumin; (5) high-sensitivity C-reactive protein; (6) oxidized low-density lipoprotein (Ox-LDL); and (7) renin, angiotensin-II, and aldosterone. There was a significant difference in the Hb levels measured before and after CERA administration. The BNP, ANP, NYHA, left ventricular mass index, renal function, and Ox-LDL decreased significantly after CERA administration. This study shows that CERA improves anemia and reduces renal impairment, as well as cardiac and oxidative stress. The result of this study is useful for a study in which switching from CERA to a new renal anemia drug, hypoxia-inducible factor prolyl-hydroxylase inhibitor, is investigated.

Coronary Artery Stenosis Caused by Primary Malignant Pericardial Mesothelioma in a 76-Year-Old Man.

This report describes a 76-year-old man with diabetes mellitus who developed coronary artery stenosis from infiltration of a primary malignant pericardial mesothelioma. Three months before referral to the treating hospital, elevated liver function values and cardiac enzymes led to echocardiography, which revealed a motion abnormality in the anterior wall of the heart. The patient was diagnosed with congestive heart failure and admitted to the hospital, where chest computed tomography showed a tumor above the left atrial appendage that compressed the origin of the left anterior descending artery. He was referred to the treating hospital for surgery. Minimally invasive direct coronary artery bypass grafting was performed, but the mass was not resected because of its infiltrating nature and the potential for medical complications. Histologic examination of a biopsy specimen confirmed a primary malignant pericardial mesothelioma. The bypass procedure resolved the coronary artery stenosis caused by the tumor. Although the optimal treatment for primary malignant pericardial mesothelioma is controversial, minimally invasive methods, such as minimally invasive direct coronary artery bypass grafting, may be used successfully.

A Case of Thoracic Aortic Endovascular Repair of a Ruptured Mycotic Aortic Aneurysm Due to Pasteurella Multocida.

An 81-year-old man was admitted for general fatigue of one month's duration. Two sets of blood cultures revealed bacteremia, due to Pasteurella multocida, while computed tomography (CT) revealed a 47-mm descending aortic saccular aneurysm. After transfer to our hospital, the saccular aneurysm rapidly grew to 54 mm. An emergency thoracic endovascular aortic repair was performed, due to the aneurysm immediately rupturing after the CT scan. The patient was discharged on postoperative day 28.

Native Valve Attachment to the Prosthetic Valve 2.5 Years After the Third Tricuspid Valve Replacement.

The native tricuspid leaflets are sometimes preserved with tricuspid valve replacement to prevent atrioventricular block or maintain right ventricular function. However, after a tricuspid valve replacement using bioprosthetic valve, a rare complication involving adhesion of the pannus formation to the prosthetic valve may occur. We report the case of a 48-year-old woman who underwent a third tricuspid valve replacement with a bioprosthetic valve for severe tricuspid regurgitation 2.5 years after the redo tricuspid valve replacement.

Exophytic cavernous hemangioma arising from the right ventricle: Report of a rare case.

Cardiac hemangioma is relatively rare, accounting for approximately 1-3% of all primary heart tumors. This benign tumor may be an incidental lesion, but can also cause arrhythmias, pericardial effusion, congestive heart failure or outflow obstruction. We report a rare case with exophytic cardiac hemangioma arising from the right ventricle. Echocardiography showed an approximately 40 mm round protruding mass on the anterior wall of the right ventricle. Cardiovascular magnetic resonance demonstrated isointense and hyperintense signals on T1- and T2-weighted images, respectively. These imaging studies suggested a pericardial cyst. Perioperative findings indicated a globular, exophytic mass, vascular in nature, arising from the right ventricle. The lesion was resected directly, and the space left by defect in the right ventricular wall was covered with a bovine pericardial patch. Cardiac hemangiomas are generally endoluminal tumors, but we must keep in mind that the differential diagnoses include various pericardial lesions by medical images.

A Comparative Prospective Observational Study on the Use of Direct Oral Anticoagulants after Cardiac Surgery for the Management of Atrial Fibrillation.

PURPOSE: Recently, guidelines recommended the use of direct oral anticoagulants (DOACs) for the management of non-valvular atrial fibrillation (NVAF). Postoperative atrial fibrillation (POAF) is the most common post-surgical complication of cardiac surgery, but the efficacy and safety of DOAC for POAF have rarely been investigated. We conducted a prospective observational study to investigate the efficacy and safety of DOAC administered immediately after POAF. MATERIALS AND METHODS: In all, 135 patients that experienced POAF after cardiac surgery were treated with a DOAC. Primary endpoints were either bleeding or thromboembolic events. Secondary endpoints included changes in hemoglobin (Hb), prothrombin time (PT), activated partial thromboplastin time (APTT), serum creatinine (sCr), estimated glomerular filtration rate (eGFR), and pleural/pericardial effusion. RESULTS: Patients were treated with apixaban (n = 31), edoxaban (n = 87), and rivaroxaban (n = 17). Major bleeding (p = 0.011) and gastrointestinal (GI) bleeding (p = 0.047) were significantly more frequent in the rivaroxaban group. Stroke was observed in one rivaroxaban group patient and none in the other two groups. CONCLUSION: DOAC as anticoagulation therapy for the early intervention of POAF following cardiac surgery is associated with a low incidence of major bleeding; a favorable safety profile and excellent efficacy were demonstrated for DOAC. Furthermore, our results indicate that the safety and efficacy of apixaban and edoxaban are better than rivaroxaban.

Iatrogenic acute aortic dissection caused by intervention for spontaneous coronary artery dissection: a surgical case report.

BACKGROUND: Iatrogenic acute aortic dissection (AAD) caused by cardiovascular intervention is rare. Also rare is spontaneous coronary artery dissection (SCAD), a form of acute coronary syndrome, which develops in relatively young women without coronary risk factors. We encountered type A iatrogenic AAD caused by an intervention for SCAD. CASE PRESENTATION: A 53-year-old woman was brought to our hospital after cardiopulmonary resuscitation. She was diagnosed with acute coronary syndrome caused by SCAD, and percutaneous coronary intervention was carried out on her distal left anterior descending artery. The dissection proceeded to the proximal left anterior descending artery and left main coronary artery trunk, so additional percutaneous coronary intervention was performed on the left circumflex artery. After the intervention, type A AAD occurred with a primary entry tear from the left main coronary artery trunk, and computed tomography showed a type A AAD of the aortic arch. We performed emergency ascending aorta replacement and coronary artery bypass grafting to the left anterior descending artery and left circumflex artery. The patient had an uneventful recovery after the operation and was discharged on postoperative day 25. CONCLUSION: To our knowledge, this is the first report of an iatrogenic AAD caused by percutaneous coronary intervention for SCAD.

New Treatment for Driveline Infection Following Implantation of a Ventricular Assist Device.

In patients with an implantable ventricular assist device (VAD), driveline infection (DLI) is a challenging complication. Once DLI occurs, it may lead to pump contamination and/or septicemia, which means that early treatment is essential. We hereby report our initial experiences of a mechanically-powered portable negative pressure wound therapy system (Smart Negative Pressure: SNaPTM) to treat DLI at an outpatient clinic.

Changeover Trial of Febuxostat and Topiroxostat for Hyperuricemia with Cardiovascular Disease: Sub-Analysis for Chronic Kidney Disease (TROFEO CKD Trial).

BACKGROUND: The TROFEO trial demonstrated that febuxostat causes greater and more rapid reduction of serum uric acid (s-UA) than topiroxostat. We compared these drugs in patients with chronic kidney disease (CKD) by sub-analysis of the TROFEO trial. METHODS: This sub-analysis targeted patients with an estimated glomerular filtration rate (eGFR) ≤60 mL/min/1.73 m2. The primary endpoint was the s-UA level. Secondary endpoints included creatinine, eGFR, urinary albumin, cystatin-C, oxidized low-density lipoprotein (Ox-LDL), eicosapentaenoic acid/arachidonic acid ratio, lipid biomarkers, high-sensitivity C-reactive protein, and B-type natriuretic peptide (BNP). RESULTS: There was no significant difference of s-UA between the two groups either before or after treatment. However, s-UA did not exceed 6.0 mg/dL in febuxostat group during the study period, but it exceeded this level in seven patients from topiroxostat group, with the number being significantly higher in topiroxostat group. Serum creatinine (s-Cr) and eGFR were significantly better after 6 months of febuxostat treatment compared with topiroxostat Cystatin-C was significantly lower after 6 months of febuxostat treatment compared with topiroxostat. The Ox-LDL was significantly lower after 3 and 6 months of febuxostat treatment compared with topiroxostat. CONCLUSION: Febuxostat had stronger renoprotective and antioxidant effects than topiroxostat in patients with hyperuricemia and CKD.

Surgery for a mitral annulus abscess penetrating into the pericardial cavity.

Although a mitral annulus abscess often develops with infective endocarditis, penetration into the pericardial cavity is a very rare and fatal complication. Herein, we report a case of surgery with thorough debridement and appropriate reconstruction for a mitral annulus abscess with penetration into the pericardial cavity.

Is malnutrition associated with postoperative complications after cardiac surgery?

BACKGROUND AND AIM: Malnutrition is the central component of frailty that has an adverse influence on the prognosis of patients undergoing cardiac surgery. The relationship between malnutrition and postoperative complications was evaluated in a retrospective cohort study. METHODS: In 287 patients undergoing elective cardiac surgery, nutritional status was assessed by using the Geriatric Nutritional Risk Index (GNRI). Then the patients were divided into a malnutrition group (GNRI <91) and a nonmalnutrition group (GNRI ≥91), after which the postoperative course was compared. RESULTS: There were 51 patients (17.8%) in the malnutrition group. Nine patients died after surgery and the operative mortality rate was significantly higher in the malnutrition group than the nonmalnutrition group (five deaths [9.8%] vs four deaths [1.8%]; P = .003). In addition, the duration of intensive care unit stay and hospital stay were both significantly longer in the malnutrition group compared with the nonmalnutrition group. Multivariate analysis showed that malnutrition was an independent predictor of hospitalization for longer than 1 month (odds ratio [OR]: 3.428; 95% confidence interval [CI]:1.687-6.964; P = .001) and a postoperative bedridden state (OR: 7.377; 95% CI:1.874-29.041; P = .004). CONCLUSIONS: Preoperative evaluation of the nutritional status using the GNRI seems to be valuable for predicting the risk of postoperative complications.

Canagliflozin for Japanese patients with chronic heart failure and type II diabetes.

BACKGROUND: Reports that sodium glucose cotransporter 2 inhibitors decrease cardiovascular death and events in patients with diabetes have attracted attention in the cardiology field. We conducted a study of canagliflozin in patients with chronic heart failure and type II diabetes. METHODS: Thirty-five Japanese patients with chronic heart failure and type II diabetes were treated with canagliflozin for 12 months. The primary endpoints were the changes of subcutaneous, visceral, and total fat areas at 12 months determined by computed tomography. Secondary endpoints included markers of glycemic control, renal function, and oxidative stress, as well as lipid parameters, atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), flow-mediated dilation (FMD), and echocardiographic left ventricular function. RESULTS: All fat areas (subcutaneous, visceral, and total) showed a significant decrease at 12 months. ANP and BNP also decreased significantly, along with improvement of renal function, oxidized LDL, and E/e', FMD increased significantly after canagliflozin treatment. CONCLUSION: Canagliflozin demonstrated cardiac and renal protective effects as well as improving oxidative stress, diastolic function, and endothelial function. This drug was effective in patients who had heart failure with preserved ejection fraction and could become first-line therapy for such patients with diabetes. Trial registration UMIN ( http://www.umin.ac.jp/ ), Study ID: UMIN000021239.

Long-Term Comparison of Ethyl Icosapentate vs. Omega-3-Acid Ethyl in Patients With Cardiovascular Disease and Hypertriglyceridemia (DEFAT Trial).

BACKGROUND: Numerous studies have demonstrated a reduction in cardiovascular events when the low-density lipoprotein cholesterol (LDL) level is decreased by statin therapy. However, despite good control of LDL, cardiovascular events may increase if the triglyceride (TG) level is high. We conducted a long-term comparison of treatment of hypertriglyceridemia with ethyl icosapentate (EPA) vs. omega-3-acid ethyl (EPA+docosahexaenoic acid [DHA]).Methods and Results:Cardiac surgery patients with hypertriglyceridemia were randomized to an EPA group (1.8 g t.i.d.) or an EPA+DHA group (2 g s.i.d.) and observed for 3 years. The primary endpoints were the serum TG level and its percent change. Secondary endpoints included lipid markers, fatty acid parameters, serum creatinine, cystatin-C, oxidized LDL, high-sensitivity C-reactive protein, and MACCE. An interview to assess study drug adherence was conducted 6 months after completing the study. TG levels were significantly lower in the EPA+DHA group than in the EPA group. Levels of remnant-like particles-cholesterol, oxidized LDL, and cystatin-C were also significantly lower in the EPA+DHA group than in the EPA group. Compliance with treatment was significantly worse in the EPA group. CONCLUSIONS: Better results were obtained in the EPA+DHA group, but more patients showed poor compliance with treatment in the EPA group, making detailed comparison of the 2 groups difficult. Even so, TG were reduced while EPA and DHA levels were increased in the EPA+DHA group, together with a reduction in oxidative stress and remnant-like particles-cholesterol. Decreased compliance with medication in the EPA group significantly affected the results of this study, clearly indicating the importance of good compliance.

Successful Surgical Treatment of Giant Coronary Artery Aneurysm and Concomitant Coronary Artery Fistula to the Pulmonary Artery.

Giant coronary artery aneurysm (GCAA) combined with coronary artery fistula to the pulmonary artery (PA) is rare. A 79-year-old man was accidentally discovered with GCAA. He was operated on by use of aneurysmorrhaphy, and closure of the fistulae was performed. Because ischemic changes appeared, coronary artery bypass grafting was done. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. We report here a case of GCAA with a size of 66 × 52 mm in diameter associated with a fistula formation into the PA. It is one of the largest sizes of GCAA that has occurred after fistula formation.

Acute experimental study of Abiomed BVS5000 as a V-A bypass to cardiogenic shock models.

PURPOSE: Abiomed BVS5000 is generally used as a ventricular assist device, and there have been no reports of its application to a veno-arterial bypass (V-A bypass). In the present study, we developed a new V-A bypass system using this pump and examined its usefulness experimentally. MATERIALS AND METHODS: Pigs (n=21; 37.4+/-2.2 kg) with cardiogenic shock were divided into the following three groups: (1) Abiomed group (Abiomed BVS5000); (2) nonpulsatile pump (NP)+intra-aortic balloon pump (IABP) group (centrifugal pump and IABP); and (3) NP group. In all three groups, assisted circulation using the pumps was performed for 3 h after the shock. Hemodynamic data and blood specimens were measured before and immediately after the shock, and again at 1, 2, and 3 h after. The individual variations were reduced by evaluation of the measured value/preshock value ratio, not by evaluation of the absolute values. RESULTS: The coronary arterial blood flows at 3 h after the shock were significantly larger in the Abiomed and NP+IABP groups than in the NP group (1.32+/-0.34 and 1.24+/-0.05 vs. 1.05+/-0.11, P<0.05), and the renal arterial and renal cortical tissue blood flows were significantly larger in the Abiomed group than in the NP+IABP and NP groups (renal artery: 1.30+/-0.17 vs. 0.89+/-0.20 and 0.68+/-0.10, P<0.05; renal cortical tissue: 0.74+/-0.25 vs. 0.62+/-0.05 and 0.43+/-0.18, P<0.05). The lactate/pyruvate ratios were significantly lower in the Abiomed groups than in the NP group (25.2+/-1.6 vs. 36.0+/-3.1, P<0.05). CONCLUSION: The results suggest that a V-A bypass using an Abiomed BVS5000 is a useful treatment for organ blood flow redistribution after shock.

Child with fulminant myocarditis survived by ECMO Support--report of a child case.

A 6-year-old girl had cold-like symptoms. Administration of antibiotics did not improve the symptoms, and the patient had chronic chest pain. Electrocardiogram (ECG) demonstrated ventricular tachycardia (VT) and cardiac enzyme levels were increased. Mexiletine and olprinone were continuously administered, but slow VT and III degrees A-V block repeatedly occurred. Pulse therapy using methyl prednisolone was performed, but hemodynamics did not improve. Ejection fraction (EF) decreased to 20%, and metabolic acidosis occurred. Extra corporeal membrane oxygenation (ECMO) was applied 24 hours after admission to the intensive care unit (ICU). To apply ECMO, a median sternotomy was performed. An in-flow cannula (15 Fr) was inserted into the ascending aorta and an out-flow cannula (19 Fr) was inserted into the right atrium. After returning to the ICU, blood pressure (BP) were stable, and urine volume was maintained at about 100 ml/h. Methyl prednisolone and gamma-globulin were administered during circulatory assisted period. About 24 hours later, sinus rhythm was obtained, and weaning was started after improvement of the EF. BP was maintained at 100 mmHg with low dose catecholamine, which was weaned off 42 hours after commencement. Hemodynamics after this remained stable. EF improved to 54.2%. An ECG demonstrated right bundle branch block (RBBB) at the sinus rhythm. Severe inflammatory changes were pathologically observed, and we diagnosed myocarditis. The patient was discharged from the hospital on 43 days post admission, and currently attends school.