Renal ultrasonography predicts worsening renal function in patients with heart failure under tolvaptan administration.

AIMS: Renal dysfunction in patients with chronic heart failure predicts a poor prognosis. Tolvaptan has a diuretic effect in patients with chronic kidney disease and heart failure without adverse effects on renal function. We aimed to determine the effects of tolvaptan and predictors of worsening renal function in patients with heart failure. METHODS AND RESULTS: This post hoc analysis was a sub-analysis of a single-centre prospectively randomized trial on the early and short-term tolvaptan administration. We enrolled 201 participants with decompensated heart failure between January 2014 and March 2019 (early group, n = 104; age: 79.0 ± 12.8 years; late group, n = 97; age: 80.3 ± 10.8 years). Renal ultrasonography was performed before and after the administration of tolvaptan. Urine output and oral water intake significantly increased during tolvaptan administration. The difference between water intake and urine volume increased during tolvaptan administration. Changes in body weight, blood pressure, heart rate, and estimated glomerular filtration rate (eGFR) in both groups were comparable. The changes in peak-systolic velocity (PSV), acceleration time (AT) of the renal arteries, and resistance index were comparable. The changes in PSV and end-diastolic velocity (EDV) of the interlobar arteries increased following tolvaptan administration (Δmax PSV: 0.0 ± 14.8 cm/s before tolvaptan vs. 5.6 ± 15.7 cm/s after tolvaptan, P = 0.002; Δmean PSV: 0.4 ± 12.3 vs. 4.9 ± 12.7 cm/s, P = 0.002; Δmax EDV: -0.2 ± 3.5 vs. 1.4 ± 4.0 cm/s, P = 0.001; Δmean EDV: -0.0 ± 3.1 vs. 1.1 ± 3.4 cm/s, P = 0.003). The renal artery AT was negatively correlated with the eGFR (Δmax AT: beta = -0.2354, P = 0.044; Δmean AT: beta = -0.2477, P = 0.035). CONCLUSIONS: Tolvaptan increased the PSV and EDV of the interlobar artery, which may mean tolvaptan increased renal blood flow. The renal artery AT may be a surrogate for worsening renal function.

Application of first-generation high- and low-dose drug-coated balloons to the femoropopliteal artery disease: a sub-analysis of the POPCORN registry.

BACKGROUND: Drug-coated balloons (DCBs) have significantly changed endovascular therapy (EVT) for femoropopliteal artery (FPA) disease, in terms of the expansion of indications for EVT for symptomatic lower extremity arterial disease (LEAD). However, whether there is a difference in the performance among individual DCBs has not yet been fully discussed. The present sub-analysis of real-world data from a prospective trial of first-generation DCBs compared the clinical outcomes between high- and low-dose DCBs using propensity score matching methods. The primary endpoint was the restenosis-free and revascularization-free rates at 1 year. RESULTS: We compared 592 pairs matched for patient and lesion characteristics using propensity score matching among a total of 2,507 cases with first-generation DCBs (592 and 1,808 cases in the Lutonix low-dose and In.PACT Admiral high-dose DCB groups, respectively). There were no differences in patient/lesion characteristics, procedural success rates, or complications between the two groups. First-generation low-dose DCB had significantly lower patency (73.3% [95% confidence interval, 69.6%-77.3%] in the low-dose DCB group versus 86.2% [84.1%-88.3%] in the high-dose DCB group; P < 0.001) and revascularization-free (84.9% [81.9%-88.1%] versus 92.5% [90.8%-94.1%]; P < 0.001) rates. Chronic kidney disease on dialysis, cilostazol use, anticoagulant use, and severe calcification had a significant interaction effect in the association (all P < 0.05). CONCLUSIONS: EVT to FPA with first-generation DCBs had inferior low-dose patency outcomes as compared with high-dose outcomes in the present cohort. LEVEL OF EVIDENCE: Sub analysis of a prospective multicenter study.

Clinical Effects of Early and Short-Term Tolvaptan Administration in Patients Hospitalized for Acute Decompensated Heart Failure.

INTRODUCTION: Previous trials showed that tolvaptan improves acute heart failure (HF). However, the optimal timing for administering tolvaptan to achieve the best outcome remains unclear. Therefore, the current study investigated the relationship between the timing of tolvaptan treatment initiation and clinical outcomes in patients with acute decompensated HF. METHODS: We prospectively evaluated 201 patients with acute decompensated HF, randomly divided into 2 groups based on the timing of tolvaptan initiation. The early group was administered tolvaptan approximately 1 week after day 1 or 2 (n = 104), whereas the late group was administered the same drug 1 week after the early group (n = 97). RESULTS: All-cause mortality, cardiovascular death, and hospitalization during the follow-up period were comparable between both groups. The early group had shorter durations of oxygenation, carperitide infusion, and hospitalization than the late group (p = 0.013, 0.003, 0.006, respectively). The early group demonstrated a significantly faster decrease in pleural effusion than the late group (p = 0.001). The 2 groups had comparable maximum and minimum serum sodium and potassium levels and minimum estimated glomerular filtration rates during hospitalization. The early group spent significantly less money on all diuretics administered over the first 2 weeks and on tolvaptan and carperitide administered during the hospitalization period than the late group (p < 0.001). CONCLUSIONS: Early and short-term administration of tolvaptan was feasible, contributed to a more rapid improvement in patients with acute decompensated HF, and reduced health-care costs.

One-Year Clinical Outcomes following Implantation of InnovaTM Self-Expanding Nitinol Stents in Patients with Peripheral Artery Diseases Presenting Femoropopliteal Artery Lesions.

AIM: Although the InnovaTM self-expanding nitinol stent (Boston Scientific, Marlborough, MA) exhibits acceptable performance in long-term safety and efficacy when used for the treatment of femoropopliteal (FP) lesions, clinical outcomes following its implantation have not been systematically studied in real-world settings. We investigated the one-year clinical outcomes after implantation of InnovaTM self-expanding nitinol stents for the treatment of FP lesions in real-world settings. METHODS: In this multicenter study, 481 lesions in 453 consecutive patients with peripheral artery disease (PAD) (74±9 years; male, 70%; diabetes mellitus, 61%; dialysis, 27%; critical limb ischemia, 37%) who underwent endovascular therapy with the implantation of InnovaTM self-expanding nitinol stents for FP lesions were analyzed from February 2016 to April 2017. The primary endpoint was one-year restenosis, whereas the secondary endpoints included one-year major adverse limb events and predictors for one-year restenosis. RESULTS: The mean lesion length was 18±10 cm. One-year restenosis and major adverse limb event rates were 36% and 18%, respectively. Multivariate analysis revealed that the presence of diabetes mellitus (odds ratio [OR]: 1.83; 95% confidence interval [CI]: 1.07-3.13), distal reference vessel diameter (OR: 1.86; 95% CI: 1.09-3.16), spot stenting (OR: 2.27; 95% CI: 1.27-4.06), and lack of one-year cilostazol treatment (OR: 0.58; 95% CI: 0.33-1.00) were independent risk factors for one-year restenosis. CONCLUSION: The current study demonstrated one-year clinical outcomes after InnovaTM self-expanding nitinol stent placement for the treatment of FP lesions, including challenging cases in real-world settings.

New Endovascular Technique to Prevent Distal Embolism for Iliofemoral Occlusive Disease: Reverse Flow Aspiration With Proximal Sheath Blockage.

PURPOSE: To report the safety and efficacy of a new technique to prevent distal embolism during treatment of iliofemoral occlusions: reverse flow aspiration with proximal sheath blockage (ReFLAP). METHOD: Between October 2013 and December 2014, 90 patients (mean age 74 years; 66 men) were prospectively enrolled in a study to evaluate the ReFLAP technique during treatment of 110 occlusions in the iliac artery (72, 65%) or superficial femoral artery (SFA; 38, 35%). The mean occlusion lengths of iliac and SFA lesions were 79 and 179 mm, respectively. The concept of ReFLAP is to aspirate debris after balloon dilation using reverse flow through collaterals without antegrade flow. The main endpoints were the incidence of distal embolization, amputation, complications, and the ReFLAP capture rate, which was visually estimated during aspiration using 4 prespecified grades (0, none; 1, foamy debris; 2, small particles; 3, massive particles). RESULTS: ReFLAP was successful in 105 (95.4%) of the 110 lesions attempted; the 5 failures were due to severe vessel tortuosity or calcification. The incidences of distal embolization and amputation were both 0. Minor complications unrelated to ReFLAP were observed in 8 patients. The ReFLAP procedure aspirated debris in 57 (54%) of the 105 lesions. Aspirated material, including marked clots (grades 2 and 3), was confirmed in 40 (38%) of the lesions. The distribution of aspiration grades was significantly different between iliac and SFA lesions (p=0.02). CONCLUSION: Our results suggest that the ReFLAP endovascular technique to prevent distal embolization during iliofemoral occlusive disease treatment is simple, safe, and effective.

Identification of causative organism in cardiac implantable electronic device infections.

BACKGROUND: The causative organism in cardiovascular implantable electronic device (CIED) infection is usually diagnosed with the cultures from blood, removed leads, and/or infected pocket material. The cultured organism, however, is sometimes different among these samples. METHODS: Two hundred sixty patients with CIED infection, who underwent lead extraction between April 2005 and December 2014, were analyzed. More than two blood culture sets, all the extracted leads, and swab culture of the pocket were sent to the laboratory for culture. Among the patients all of whose microbiological examinations were available, we analyzed the causative organism defined as the species detected in at least two different sites. RESULTS: All the culture results were available in the 208 patients, showing 69 systemic infections (including 30 cases of infectious endocarditis) and 139 local infections. Blood culture, lead culture, and swab culture were positive in 57 (27%), 169 (81%), and 152 (73%), respectively. Staphylococcus aureus [37% including methicillin-resistant S. aureus (MRSA) (12%)] and coagulase-negative staphylococci (CoNS, 36%) were the most common causative organism, followed by non-staphylococci (23%), and poly-microbial infection (4%). The detection of S. aureus from pocket or removed leads rendered higher predictive value of a causative organism than that of CoNS. The detection of Gram-negative bacteria, fungi, and mycobacteria indicated that it was most likely a causative organism. Gram-positive bacteria excluding Staphylococcus, such as Corynebacterium spp., tended to coexist as a benign organism. CONCLUSIONS: The causative organism is mostly S. aureus and CoNS. Detection of S. aureus or Gram-negative bacteria means that it is more likely a causative organism.

Validation of pressure gradient and peripheral fractional flow reserve measured by a pressure wire for diagnosis of iliofemoral artery disease with intermediate stenosis.

OBJECTIVE: To examine the pressure gradient and peripheral fractional flow reserve (pFFR) measured by a pressure wire as indicators of hemodynamic significance in iliofemoral angiographic intermediate stenosis. BACKGROUND: The utility of pressure measurements using a pressure wire with vasodilators is unclear in cases with intermediate iliofemoral stenosis. METHODS: The mean pressure gradient (MPG) and mean pressure ratio (MPR) were measured at baseline and after injection of isosorbide dinitrate in 23 lesions with angiographically intermediate iliofemoral stenosis. Patients with complex lesions, infrapopliteal artery lesions, chronic total occlusion, and surgical bypass grafts were excluded. Hyperemic MPR was considered equivalent to pFFR. Changes in parameters in response to vasodilators were assessed and correlations of peak systolic velocity ratio (PSVR) with hyperemic MPG and pFFR were examined using duplex ultrasound. RESULTS: After injection of isosorbide dinitrate, hyperemic MPG increased significantly (from 9.0±5.7 to 16.3±6.2 mmHg; P<0.05) and hyperemic MPR (pFFR) decreased significantly (from 0.92±0.06 to 0.81±0.07; P<0.05). PSVR was significantly correlated with hyperemic MPG (R=0.52; P<0.05) and pFFR (R=-0.50; P<0.05). The optimal cut-off value of pFFR as an indicator of significant hemodynamic stenosis (PSVR >2.5) was 0.85 (area under the curve 0.72; sensitivity 94%; specificity 50%, P<0.05). CONCLUSION: pFFR measured using a pressure wire is reliable for prediction of hemodynamic significance in iliofemoral intermediate stenosis.

A case of fulminant myocarditis associated with novel N1H1 influenza successfully treated by percutaneous cardiopulmonary support system.

We report a case of fulminant myocarditis associated with N1H1 influenza virus infection. N1H1 was confirmed by a polymerase chain reaction assay and she was treated with oseltamivir phosphate. She was admitted to the hospital because of respiratory distress, however, echocardiography revealed severely depressed wall motion followed by refractory ventricular fibrillation. Extracorporeal circulation by emergent percutaneous cardiopulmonary support system was required to maintain hemodynamic stability. Cardiac function was spontaneously and gradually restored within a week. Findings from biopsy samples taken on day 1 and day 23 were consistent with acute myocarditis.