Incremental value of tricuspid annular enlargement to progressive tricuspid regurgitation in patients with longstanding persistent atrial fibrillation.

Tricuspid annular enlargement in patients with atrial fibrillation (AF) can induce tricuspid regurgitation (TR). However, risk factors associated with TR progression in patients with AF have not been defined. This study aimed to clarify an association between tricuspid annular diameter (TAD) and TR progression in patients with longstanding persistent AF. We retrospectively analyzed data from 228 patients who had longstanding persistent AF for > 1 year and mild or less TR on baseline echocardiograms. We defined significant TR as moderate or greater TR, graded according to the jet area and vena contracta. The optimal cut-off value of the TAD index (TADI), based on body surface area for predicting progression to significant TR, was estimated using receiver operating characteristic (ROC) curves. The independence and incremental value of the TADI were evaluated using multivariate Cox proportional hazard regression analysis and likelihood ratio tests. Over a median follow-up of 3.7 years, 55 (24.1%) patients developed significant TR. The optimal cut-off value of 21.1 mm/m2 for the TADI at baseline and ROC curves predicted TR progression with 70.4% sensitivity and 86% specificity. Furthermore, TADI was an independent predictor of TR progression (hazard ratio, 1.32; 95% confidence interval, 1.17-1.49, P < 0.001) and had a significant incremental value that exceeded that of models constructed using clinical parameters. In conclusion, TADI was significantly associated with TR progression and was an independent predictor of TR progression in longstanding persistent AF.

Right ventricular papillary muscle crossing the moderator band mimicked infective endocarditis: the utility of multimodal imaging.

Right-sided infective endocarditis (RSIE) generally carries a positive prognosis; however, it can result in complications such as heart failure, underscoring the importance of prompt diagnosis. While echocardiography serves as the standard diagnostic tool, it may occasionally face challenges in distinguishing between normal structures and vegetations. In this report, we present the case of a 60-year-old man diagnosed with pyogenic vertebral osteomyelitis, alongside suspected coexisting RSIE. During both transthoracic and transesophageal echocardiography, a rod-like mobile structure was observed adjacent to the right ventricular moderator band. However, confirming its nature as an infective vegetation proved challenging. Despite the inconclusive diagnosis of IE by echocardiography, the positron emission tomography/computed tomography (PET/CT) scan and cardiac magnetic resonance imaging (MRI) played a pivotal role in distinguishing between normal structures and vegetations. Since IE could develop life-threatening events, the role of multimodal imaging is of paramount importance. This case serves as a compelling example of the diagnostic value through the integration of PET/CT and MRI in ruling out IE.

A prediction model for estimating NT-proBNP in a general Japanese population: the Toon Health Study.

AIMS: As part of the Toon Health Study, which is an ongoing population-based cohort study, we aimed to develop a prediction model for N-terminal pro-brain natriuretic peptide (NT-proBNP) in a general Japanese population. We sought to explore the influence of various demographic and clinical factors on NT-proBNP levels and assess the model's performance. In addition, our objectives included internal validation and investigation of the diagnostic potential of the observed-to-predicted NT-proBNP ratio (OPR) at baseline for predicting the risk of heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS: In this prospective cohort study, participants were recruited from Toon City, Japan, as part of the larger Toon Health Study, focusing on cardiovascular risk factors. We measured the NT-proBNP levels and used linear regression with penalization (ridge regression) to develop the model. The model incorporated 10 prespecified predictors (age, gender, body mass index, diastolic blood pressure, heart rate, haemoglobin, albumin, total cholesterol, haemoglobin A1c, and estimated glomerular filtration rate) and underwent assessment using R2 and root mean squared error (RMSE). Internal validation was conducted through bootstrapping. In a post hoc analysis, we explored the OPR's diagnostic potential using 5 year follow-up data (n = 636) to predict the elevation of NT-proBNP > 125 pg/mL at the 5 year follow-up as the risk of HFpEF. A total of 2505 participants (age: 60.4 ± 12.9 years, men: 35%) were enrolled in this study. There was a linear relationship between the observed and predicted values of NT-proBNP in which the logarithm of observed NT-proBNP was <6, which corresponds to 403 pg/mL in NT-proBNP. The prediction model demonstrated satisfactory performance (R2: 0.291, RMSE: 0.688), with age identified as a dominant predictor. The stability of the model was underscored by the internal validation. The OPR at baseline predicted NT-proBNP > 125 pg/mL at the 5 year follow-up with an area under the curve of 0.793. CONCLUSIONS: This study introduces the first prediction model for NT-proBNP in a general Japanese population. Although the model has acceptable performance, ongoing refinement is essential. Our transparent approach to model development, alongside a web-based interactive tool, lays the groundwork for further improvements and external validation. The OPR holds potential for predicting the future risk of HFpEF. This research contributes to understanding the nuanced influence of patient backgrounds on levels of NT-proBNP in asymptomatic individuals within the context of a broader population-based cohort study.

Distinctive left ventricular-arterial and right ventricular-pulmonary arterial coupling observed in patients with heart failure and a higher left ventricular ejection fraction range.

AIMS: Higher left ventricular (LV) ejection fraction (EF) is related to unfavourable prognosis in patients with heart failure (HF) with preserved ejection fraction (HFpEF). The cause of this finding needs to be hemodynamically explained. Thus, we investigated this crucial issue from the perspective of LV-arterial (A) and right ventricular (RV)-pulmonary arterial (PA) coupling. METHODS AND RESULTS: Study patients were derived from our prospective cohort study of patients hospitalized due to acute decompensated HF and LVEF>40%. We divided the 255 patients into 3 groups: HF with mildly reduced EF (HFmrEF), HFpEF with 50%≤LVEF<60%, and HFpEF with LVEF≥60%. We compared LV end-systolic elastance (Ees), effective arterial elastance (Ea), and Ees/Ea as a representative of LV-A coupling among groups, and compared the ratio of tricuspid annular plane excursion to peak pulmonary arterial systolic pressure (TAPSE/PASP) as a representative of RV-PA coupling. All-cause death and readmission due to HF-free survival was worse in the group with a higher LVEF range. Ees/Ea was greater in HFpEF patients with LVEF≥60% (2.12±0.57) than in those with 50%≤LVEF<60% (1.20±0.14) and those with HFmrEF (0.82±0.09) (P<0.001). PASP was increased in the groups with higher LVEF; however, TAPSE/PASP did not differ among groups (n=168, P=0.17). In a multivariate Cox proportional-hazard model, TAPSE/PASP but not PASP was significantly related to event-free survival independent of LVEF. CONCLUSION: HFpEF patients with higher LVEF have unfavourable prognosis and distinctive LV-A coupling: Ees/Ea is elevated up to 2.0 or more. Impaired RV-PA coupling also worsens prognosis in such patients.

Adenosine triphosphate-induced life-threatening arrhythmia.

A 68-year-old woman with idiopathic dilated cardiomyopathy presented with a wide QRS complex regular tachycardia five days after mitral valve replacement. Adenosine triphosphate (ATP) was administered to make the correct diagnosis; however, tachycardia eventually transitioned to ventricular fibrillation, which required cardioversion. Although ATP is considered a relatively safe drug, it can cause unexpected, life-threatening arrhythmias. Careful monitoring and preparation are advised during ATP administration in the event of a regular wide QRS complex tachycardia in patients with irritable conditions. Learning objective: Adenosine triphosphate (ATP) is considered a safe drug that is often used to manage wide QRS complex tachycardia. Herein, we present a case of regular, wide QRS complex tachycardia in a patient who underwent mitral valve replacement. Tachycardia degenerated into ventricular fibrillation soon after ATP administration, probably because of sympathetic overdrive secondary to the ATP infusion. It is advisable to use ATP with caution, especially in irritable cases such as in the early post-cardiac surgery period.

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.

Automated categorization of virtual reality studies in cardiology based on the device usage: a bibliometric analysis (2010-2022).

Aims: Currently, virtual reality (VR) constitutes a vital aspect of digital health, necessitating an overview of study trends. We classified type A studies as those in which health care providers utilized VR devices and type B studies as those in which patients employed the devices. This study aimed to analyse the characteristics of each type of studies using natural language processing (NLP) methods. Methods and results: Literature related to VR in cardiovascular research was searched in PubMed between 2010 and 2022. The characteristics of studies were analysed based on their classification as type A or type B. Abstracts of the studies were used as corpus for text mining. A binary logistic regression model was trained to automatically categorize the abstracts into the two study types. Classification performance was evaluated by accuracy, precision, recall, F-1 score, and c-statistics of the receiver operator curve (ROC) analysis. In total, 171 articles met the inclusion criteria, where 120 (70.2%) were type A studies and 51 (29.8%) were type B studies. Type A studies had a higher proportion of case reports than type B studies (18.3% vs. 3.9%, P = 0.01). As for abstract classification, the binary logistic regression model yielded 88% accuracy and an area under the ROC of 0.98. The words 'training', '3d', and 'simulation' were the most powerful determinants of type A studies, while the words 'patients', 'anxiety', and 'rehabilitation' were more indicative for type B studies. Conclusions: NLP methods revealed the characteristics of the two types of VR-related research in cardiology.

Role of the right ventricular contractile reserve during low-load exercise in predicting heart failure readmission.

BACKGROUND: Exercise intolerance in patients with heart failure (HF) increases HF-associated readmission, and right ventricular (RV) contractile reserve assessed by low-load exercise stress echocardiography (ESE) is associated with exercise intolerance. This study investigated the impact of RV contractile reserve evaluated by low-load ESE on HF readmission. METHODS: We prospectively examined 81 consecutive patients hospitalized for HF who underwent low-load ESE under a stabilized HF condition between May 2018 and September 2020. We performed a 25-W low-load ESE and defined RV contractile reserve as the increment in RV systolic velocity (RV s'). The primary outcome was hospital readmission. Incremental values of the change in RV s' over a readmission risk (RR) score were analyzed using the receiver operating characteristic (ROC) area under the curve; internal validation using bootstrapping was performed. The association between RV contractile reserve and HF readmission was illustrated with the Kaplan-Meier curve. RESULTS: Eighteen (22 %) patients were readmitted due to worsening HF during the observation period (median 15.6 months). The cut-off value of 0.68 cm/s for the change in RV s' to predict HF readmission with the ROC curve analysis indicated good sensitivity (100 %) and specificity (76.2 %). The discriminatory ability for HF readmission was significantly improved by adding the change in RV s' to the RR score (p = 0.006), and the c-statistic using the bootstrap method was 0.92. The cumulative survival rate free of HF readmission was significantly lower in patients with reduced-RV contractile reserve (log-rank test, p < 0.001). CONCLUSIONS: The change in RV s' during low-load exercise had an incremental prognostic value for predicting HF readmission. The results demonstrated the loss of RV contractile reserve assessed by low-load ESE was associated with HF readmission.

Left atrial strain assessment using cardiac computed tomography in patients with hypertrophic cardiomyopathy.

PURPOSE: To evaluate left atrial (LA) function in patients with hypertrophic cardiomyopathy (HCM) by LA strain assessment using cardiac computed tomography (CT-derived LA strain). MATERIALS AND METHODS: This was a retrospective study of 34 patients with HCM and 31 non-HCM patients who underwent cardiac computed tomography (CT) using retrospective electrocardiogram-gated mode. CT images were reconstructed every 5% (0-95%) of the RR intervals. CT-derived LA strain (reservoir [LASr], conduit [LASc], and booster pump strain [LASp]) were semi-automatically analyzed using a dedicated workstation. We also measured the left atrial volume index (LAVI) and left ventricular longitudinal strain (LVLS) for the left atrial and ventricular functional parameters to assess the relationship with CT-derived LA strain. RESULTS: CT-derived LA strain significantly correlated with LAVI: r = - 0.69, p < 0.001 for LASr; r = - 0.70, p < 0.001 for LASp; and r = - 0.35, p = 0.004 for LASc. CT-derived LA strain also significantly correlated with LVLS: r = - 0.62, p < 0.001 for LASr; r = - 0.67, p < 0.001 for LASc; and r = - 0.42, p = 0.013 for LASp. CT-derived LA strain in patients with HCM was significantly lower than that in non-HCM patients: LASr (20.8 ± 7.6 vs. 31.7 ± 6.1%, p < 0.001); LASc (7.9 ± 3.4 vs. 14.2 ± 5.3%, p < 0.001); and LASp (12.8 ± 5.7 vs. 17.6 ± 4.3%, p < 0.001). Additionally, CT-derived LA strain showed high reproducibility; inter-observer correlation coefficients were 0.94, 0.90, and 0.89 for LASr, LASc, and LASp, respectively. CONCLUSION: CT-derived LA strain is feasible for quantitative assessment of left atrial function in patients with HCM.

Premature atrial contraction immediately after catheter ablation was associated with late recurrence of atrial fibrillation.

BACKGROUND: Although premature atrial contractions (PACs) just after catheter ablation (CA) for atrial fibrillation (AF) are common, their clinical significance is uncertain. This study aimed to evaluate whether the PAC burden after an initial CA for AF was associated with late recurrence. METHODS: We enrolled 346 patients with AF (median age, 65 years; 30% female; 57% with paroxysmal AF) who underwent an initial radiofrequency CA and a 24-h Holter monitoring the day after the procedure. PAC was defined as supraventricular complexes occurring ≥30% earlier than expected compared with a previous RR interval, and the number of PAC/24 h during post-procedural Holter monitoring was analyzed. RESULTS: AF recurred in 106 patients (31%) during a median follow-up of 19 months. These patients had significantly more PAC/24 h than those without (median [interquartile range], 891 [316-4351] beats vs. 409 [162-1,303] beats; p < 0.01). The number of PACs was independently associated with AF recurrence after adjustment for clinical parameters and left atrial (LA) enlargement. Receiver operating characteristic (ROC) curve analysis revealed that 1431 PAC/24 h was the optimal cut-off value for predicting AF recurrence. Adding the PAC/24 h to the prediction model with LA diameter appeared to correctly reclassify patients who were thought to be at high risk for AF recurrence into the low-risk group and vice versa. CONCLUSIONS: The number of PACs was an independent risk factor for AF recurrence. A 24-h Holter recording the day after an initial CA is a simple and beneficial tool for the risk stratification of AF recurrence.

LOX-1 deficiency increases ruptured abdominal aortic aneurysm via thinning of adventitial collagen.

Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is a key mediator of inflammation and plays an important role in the pathogenesis of atherosclerosis. Conversely, LOX-1 deficiency has been shown to decrease inflammation and atherosclerosis, both of which have been proposed to contribute to abdominal aortic aneurysm (AAA) pathogenesis. However, the role of LOX-1 in AAA pathogenesis remains unknown. Here, we investigated the effects of Olr1 (which encodes LOX-1) deletion on angiotensin II (Ang II)-induced AAA in apolipoprotein E knockout (ApoE KO) mice to determine whether LOX-1 deficiency mitigates AAA development. To accomplish this, we used serial, non-invasive ultrasound assessment, which revealed that the incidence and expansion rate of AAA were similar regardless of Olr1 deletion. However, Olr1 deletion significantly increased severe AAAs, including ruptured AAAs resulting in death. Oil Red O staining of the harvested aortas showed that the extent of atheroma burden localized in aneurysmal lesions did not differ between LOX-1-deficient and control mice, suggesting that Olr1 deletion did not decrease atheroma burden in the aneurysmal wall. Further histopathological analysis revealed that aneurysmal lesions in LOX-1-deficient mice had fewer fibroblasts and myofibroblasts, as well as thinner adventitial collagen, although the degree of elastin fragmentation or disruption was similar between LOX-1-deficient and control mice. An in vitro study confirmed that the proliferation of adventitial fibroblasts collected from LOX-1-deficient mice was significantly attenuated despite Ang II stimulation. In conclusion, Olr1 deletion may not mitigate aneurysm development but rather increases the vulnerability of rupture by suppressing adventitial fibroblast proliferation and collagen synthesis.

Unfavourable outcomes in patients with heart failure with higher preserved left ventricular ejection fraction.

AIMS: Newly introduced drugs for heart failure (HF) have been reported to improve the prognosis of HF with preserved ejection fraction (HFpEF) in the lower range of left ventricular ejection fraction (LVEF). We hypothesized that a higher LVEF is related to an unfavourable prognosis in patients with HFpEF. METHODS AND RESULTS: We tested this hypothesis by analysing the data from a prospective multicentre cohort study in 255 patients admitted to the hospital due to decompensated HF (LVEF > 40% at discharge). The primary endpoint of this study was a composite outcome of all-cause death and readmission due to HF, and the secondary endpoint was readmission due to HF. LVEF and the mitral E/e' ratio were measured using echocardiography. In multicovariate parametric survival time analysis, LVEF [hazard ratio (HR) = 1.046 per 1% increase, P = 0.001], concurrent atrial fibrillation (AF) (HR = 3.203, P < 0.001), and E/e' (HR = 1.083 per 1.0 increase, P < 0.001) were significantly correlated with the primary endpoint. In addition to these covariates, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) use was significantly correlated with the secondary endpoint (HR = 0.451, P = 0.008). Diagnostic performance plot analysis demonstrated that the discrimination threshold value for LVEF that could identify patients prone to reaching the primary endpoint was ≥57.2%. The prevalence of AF or E/e' ratio did not differ significantly between patients with LVEF ≥ 58% and with 40% < LVEF < 58%. CONCLUSION: A higher LVEF is independently related to poor prognosis in patients with HFpEF, in addition to concurrent AF and an elevated E/e' ratio. ACEI/ARB use, in contrast, was associated with improved prognosis, especially with regard to readmission due to HF. CLINICAL TRIAL REGISTRATION: https://www.umin.ac.jp/ctr/index.htm. UNIQUE IDENTIFIER: UMIN000017725.