Identifying the Trends of Urinary microRNAs within Extracellular Vesicles for Esophageal Cancer.

Background: The advancement of multidisciplinary treatment has increased the need to develop tests to monitor tumor burden during treatment. We herein analyzed urinary microRNAs within extracellular vesicles from patients with esophageal squamous cell carcinoma (ESCC) and normal individuals using a microarray. Methods: Patients with advanced ESCC who underwent esophagectomy (A), endoscopic submucosal resection (ESD) (B), and healthy donors (C) were included. Based on microRNA expression among the groups (Analysis 1), microRNAs with significant differences between groups A and C were selected (Analysis 2). Of these candidates, microRNAs in which the change between A and C was consistent with the change between B and C were selected for downstream analysis (Analysis 3). Finally, microRNA expression was validated in patients with recurrence from A (exploratory analysis). Results: For analysis 1, 205 microRNAs were selected. For Analyses 2 and 3, the changes in 18 microRNAs were consistent with changes in tumor burden as determined by clinical imaging and pathological findings. The AUC for the detection of ESCC using 18 microRNAs was 0.72. In exploratory analysis, three of eighteen microRNAs exhibited a concordant trend with recurrence. Conclusions: The current study identified the urinary microRNAs which were significantly expressed in ESCC patients. Validation study is warranted to evaluate whether these microRNAs could reflect tumor burden during multidisciplinary treatment for ESCC.

Conversion surgery for gastric remnant cancer with liver metastasis after nivolumab combination chemotherapy achieving pathological complete response: a case report and literature review.

BACKGROUND: Nivolumab combination chemotherapy has recently emerged as a potential first-line treatment for patients with unresectable or metastatic gastric cancer (GC). Further research has indicated that R0 resection by conversion surgery could be an effective treatment strategy to improve overall survival. However, there have been limited reports on the successful application of conversion surgery following combination chemotherapy achieving pathological complete response (pCR) in cases of advanced gastric remnant cancer with liver metastasis. Here, we present a case of long-term survival in a patient who underwent this treatment. CASE PRESENTATION: A 54-year-old man was initially referred to our department for treatment of stage III (cT3N1M0) gastric cancer where he underwent laparoscopic distal gastrectomy and D2 lymph node dissection. After a year of uneventful follow-up, the patient was diagnosed with a tumor in the gastric remnant combined with liver metastasis, resulting in a diagnosis of stage IV (cT3N0M1) gastric remnant cancer. Subsequently, the patient was treated with four cycles of TS-1, Oxaliplatin, and Nivolumab as the first-line regimen. Remarkably, both the remnant tumor and liver metastasis exhibited significant shrinkage, and no new lesions were found. Given this response, conversion surgery was performed to achieve complete resection of the remnant gastric cancer and liver metastasis, followed by laparoscopic remnant gastrectomy and partial hepatectomy. Pathological examination revealed the absence of residual carcinoma cells and lymph node metastases. Postoperatively, the patient was treated with adjuvant chemotherapy with S-1 for 1 year, and survived without recurrence for 18 months after conversion surgery. CONCLUSIONS: Nivolumab combination chemotherapy shows promise as a clinically beneficial treatment approach for gastric remnant cancer with liver metastasis, particularly when pCR can be achieved following conversion surgery.

Maximum abdominal excursion assessment using an abdominal excursion measuring device: Reliability and validity of a new device for simple and quantitative assessment of respiratory function.

This study aimed to verify the reliability and validity of abdominal expansion and respiratory function measurements. Forty healthy adult males underwent lung capacity, effort lung capacity, respiratory muscle strength, cough strength, diaphragm ultrasound, and abdominal expansion measurements. Abdominal expansion was measured using a device developed to accurately evaluate abdominal movements and calculate maximum abdominal expansion on the ventral side (AE-max: the difference between maximal abdominal contraction at the same time as maximal-effort expiration and maximal abdominal expansion at the same time as maximal-effort inspiration). Intra- and inter-rater reliabilities of the AE-max measurements were examined, the paired t-test was used for assessing the ratios of the expansion and contraction displacement components in AE-max, and regression analysis was used to obtain equations for predicting maximum inspiratory pressure (MIP) based on AE-max. Both intra- and inter-rater reliabilities were high. Criterion-related validity showed that AE-max was associated with all respiratory function parameters, especially MIP, and a high percentage of expansion displacement. Regression analysis showed that AE-max was significantly associated with MIP. Based on its association with MIP, the large proportion of expansion displacement in AE-max, and the results of the multiple regression analysis, we conclude that AE-max is a helpful measure for estimating MIP.

Remnant gastritis in gastric cancer patients causes loss of muscle mass 6 months after gastrectomy: a retrospective cohort study of Helicobacter pylori infection.

PURPOSE: In this study, we assessed the relationship between remnant gastritis and muscle mass loss and then investigated the potential relationship between Helicobacter pylori (HP) infection and remnant gastritis and muscle loss. METHODS: We reviewed the medical records of 463 patients who underwent distal gastrectomy between January 2017 and March 2020. Of these patients, 100 with pStage I after laparoscopic surgery were included in this analysis. RESULTS: A multivariate analysis showed that the total Residue, Gastritis, Bile (RGB) classification score, which indicates the degree of gastritis, was significantly associated with the rate of change (rate of decrease) in the psoas muscle area (PMA) during the first 6 months after surgery (p = 0.014). Propensity score matching was performed according to HP infection, and the rate of change in the PMA and the degree of remnant gastritis in 56 patients were compared. Neither was significantly associated with HP infection. CONCLUSIONS: Remnant gastritis did contribute to psoas muscle mass loss during the initial 6 months after gastrectomy, and HP infection was not significantly associated with either remnant gastritis or psoas muscle mass loss. Nevertheless, the potential for HP eradication to prevent muscle loss and improve the survival prognosis for gastrectomy patients merits further research.

Influence of Daily Aerobic Exercise Duration on Phase 2 Cardiac Rehabilitation at a Rehabilitation Hospital and Health-Related Quality of Life After Discharge.

Background: Phase 2 in-patient cardiac rehabilitation (CR) at a rehabilitation hospital is now added the medical service fees in Japan and in light of the recent reimbursement for CR, a study needed to be performed to determine exertional exercise on its effectiveness and benefits to patients. We examined the effects of daily aerobic exercise duration on health-related quality of life (HR-QoL) at 6 months after discharge from phase 2 CR. Methods: Of the 54 consecutive cardiovascular disease patients admitted to a rehabilitation hospital after acute care, 43 were considered acceptable candidates for enrollment according to predetermined inclusion and exclusion criteria. Of these, 40 patients completed study requirements, including return of a questionnaire on HR-QoL survey 6 months after discharge. The primary outcome was HR-QoL as evaluated using the EuroQol five-dimension five-level (EQ-5D-5L). Two multiple regression models were constructed to assess the influences of daily aerobic exercise duration (content of rehabilitation) and other clinicodemographic variables assessed during acute care (model 1) or at transfer from acute care to a rehabilitation hospital (model 2). Results: Both model 1, which included age, Barthel index of daily function before hospitalization, and daily aerobic exercise duration in the rehabilitation hospital (R2 = 0.553, P < 0.001), and model 2, which included New York Heart Association functional classification at transfer, Charlson comorbidity index at transfer, and daily aerobic exercise duration (R2 = 0.336, P = 0.002) identified aerobic exercise duration as a significant independent factor influencing HR-QoL at 6 months post-discharge (model 1: P = 0.041; model 2: P = 0.010). Conclusions: Enhanced daily aerobic exercise content during phase 2 in-hospital CR can significantly improve longer-term HR-QoL among cardiovascular disease patients independently of other clinicodemographic factors, including age, activities of daily living before treatment, and baseline condition at rehabilitation onset. These findings, that in the small sample size, support the continued expansion of phase 2 CR at a rehabilitation hospital in Japan.

Tumor Burden Monitoring with Circulating Tumor DNA During Treatment in Patients with Esophageal Squamous Cell Carcinoma.

BACKGROUND: To guide appropriate treatment strategy, an accurate tumor monitoring modality that reflects tumor burden during neoadjuvant treatment is required for esophageal squamous cell carcinoma (ESCC). We aimed to investigate the clinical utility of circulating tumor DNA (ctDNA) in plasma in patients who received neoadjuvant chemotherapy (NAC) followed by esophagectomy. PATIENTS AND METHODS: Longitudinally collected plasma samples for ctDNA combined with genomic DNA from primary lesions were obtained from patients with histologically confirmed ESCC who underwent NAC followed by subtotal esophagectomy. Next-generation sequencing was performed to identify mutations from the plasma and the primary tumor. The relationships between changes in ctDNA and the pathological response and recurrence were assessed in patients with locally advanced ESCC. RESULTS: In pretreatment samples from 13 patients, multiple concordant mutations in ctDNA and primary tumors were observed in 11 patients (85%), who were classified as ctDNA positive before treatment. The ctDNA positive rate after NAC correlated with the pathological response (responders, 25%; nonresponders, 100%; p = 0.007). The risk of recurrence increased significantly in patients with positive ctDNA after surgery in analysis of 16 patients; the 1-year recurrence-free survival rates were 90 and 0% in ctDNA-negative and ctDNA-positive groups, respectively (p = 0.0008). In two patients with postoperative recurrence, ctDNA was detected approximately 5.5 months earlier than the diagnosis using radiographical imaging. CONCLUSIONS: ctDNA is a promising biomarker for predicting pathological response and postoperative recurrence in ESCC. To demonstrate the external validity, we are currently preparing a multicenter prospective study.

Predictors of sedation period for critical illness patients focusing on early rehabilitation on the bed.

There are various interventions of rehabilitation on the bed, but these are time-consuming and cannot be performed for all patients. The purpose of this study was to identify the patients who require early mobilization based on the level of sedation. We retrospectively evaluated the data of patients who underwent physical therapy, ICU admission of > 48 h, and were discharged alive. Sedation was defined as using sedative drugs and a Richmond Agitation-Sedation Scale score of < - 2. Multiple regression analysis was performed using sedation period as the objective variable, and receiver operating characteristic (ROC) curve and Spearman's rank correlation coefficient were performed. Of 462 patients admitted to the ICU, the data of 138 patients were analyzed. The Sequential Organ Failure Assessment (SOFA) score and non-surgery and emergency surgery cases were extracted as significant factors. The ROC curve with a positive sedation period of more than 3 days revealed the SOFA cutoff score was 10. A significant positive correlation was found between sedation period and the initial day on early mobilization. High SOFA scores, non-surgery and emergency surgery cases may be indicators of early mobilization on the bed in the ICU.

Impact of loss of skeletal muscle mass within 6-12 months after gastrectomy and S1 adjuvant chemotherapy on the survival prognosis of elderly patients with gastric cancer.

BACKGROUND AND PURPOSE: We investigated the impact of postoperative changes in the psoas muscle mass index (PMI) after gastrectomy and S1 adjuvant chemotherapy (AC) on the long-term outcomes of elderly patients with gastric cancer. METHODS: We reviewed the medical records of 228 patients aged over 75 years, who underwent distal, proximal, or total gastrectomy between January, 2013 and March 2017. Among these patients, 78 with pStage IIA-IIIC who survived for at least 1 year without recurrence after gastrectomy were the subjects of this analysis. RESULTS: The log-rank test using the cut-off value from the rate of change in PMI from 6 to 12 months after gastrectomy (late rate of decrease) showed significantly poorer prognosis for the group above the cut-off value for both overall survival (OS) and recurrence-free survival (RFS) (RFS: PMI decrease ≥ 1.55%, p < 0.001; OS: PMI decrease ≥ 1.55%, p < 0.001). Patients with a relative dose intensity of S1 below 68.7% and a late rate of decrease in PMI above 1.55% were found to have a poor prognosis. CONCLUSION: It is necessary to prevent decline in the PMI of elderly patients from 6 months after gastrectomy and to administer adjuvant chemotherapy with about two-thirds or more RDI of S1 to improve their survival prognosis.

Impact of the first era of the coronavirus disease 2019 pandemic on gastric cancer patients: a single-institutional analysis in Japan.

BACKGROUND: Little is known about the disadvantages of the coronavirus disease 2019 (COVID-19) pandemic in patients with gastric cancer. This study aimed to examine the negative impact of the COVID-19 pandemic on patients with gastric cancer in the first era in Japan. METHODS: This retrospective study included 725 patients diagnosed with gastric cancer who visited our hospital between April 2019 and March 2021. The number of patients and their characteristics before and during the COVID-19 pandemic were compared. RESULTS: The number of patients diagnosed with gastric cancer during the COVID-19 pandemic decreased by 26.2% (from 417 to 308; p = 0.013) compared to that before the COVID-19 pandemic. There was a significant decrease in cStage I cancer and an increase in cStage III cancer (p = 0.004). Patients were often symptomatic (p = 0.029), especially those with stenosis-related symptoms (p < 0.001) and longer symptom duration (p < 0.001). The number of endoscopic resections was decreased by 34.8% (p = 0.005). The number of total gastrectomy was higher than that of partial gastrectomy (p = 0.021). The median time to treatment was significantly shorter (p < 0.001). CONCLUSIONS: In Japan, delays diagnosing patients with gastric cancer, probably due to refraining from consultation, may have resulted in an increase in the diagnosis of advanced-stage cancer. Moreover, an increasing proportion of patients required more invasive gastrectomy. Therefore, it may be necessary to educate patients not to refrain from consultation, even during the COVID-19 pandemic, as it can have a negative impact on treatment, policy decision, and prognosis of gastric cancer.

Short-term outcomes of robot-assisted minimally invasive esophagectomy with extended lymphadenectomy for esophageal cancer compared with video-assisted minimally invasive esophagectomy: A single-center retrospective study.

BACKGROUND: The safety and feasibility of robot-assisted minimally invasive esophagectomy (RAMIE) remain unclear. The aim of this study was to compare the short-term outcomes of RAMIE with extended lymphadenectomy and conventional minimally invasive esophagectomy (MIE) in order to investigate the safety and feasibility of RAMIE. METHODS: A retrospective analysis of 87 patients who underwent minimally invasive esophagectomy at our institution between April 2018 and March 2020 was made, assigning 22 in the RAMIE group and 65 in the MIE group. Short-term clinical outcomes and clinical baseline data were compared. RESULTS: The baseline characteristics were comparable. No significant difference in median thoracic phase blood loss and median number of dissected mediastinal lymph nodes were observed. The median operative time of thoracic approach was significantly longer in the RAMIE group than the MIE group (305 minutes [221-397] vs 227 minutes [133-365], P < .0001). With respect to postoperative complications such as recurrent laryngeal nerve paralysis (Clavien-Dindo ≥ grade II) (RAMIE 4.6% vs MIE 17%, P = .11) and postoperative pneumonia (Clavien-Dindo ≥ grade III) (RAMIE 9% vs MIE 23%, P = .13), no significant difference was observed. The patients in the RAMIE group had a better postoperative swallowing function (P = .023) and were able to start oral food intake significantly earlier (P = .007). The median hospital stay was significantly shorter in the RAMIE group than in the MIE (23 days vs 35 days, P = .009). CONCLUSIONS: RAMIE with extended lymphadenectomy was safe and feasible for esophageal cancer and resulted in improved postoperative swallowing function and shorter postoperative hospital stay.

Determining Factors for Independent Walking in Patients Undergoing Cardiovascular Surgery: Differences between Coronary Artery Bypass Grafting, Heart Valve Surgery, and Aortic Surgery.

Physical deconditioning often occurs during the acute phase after cardiovascular surgery, and unassisted walking is required to achieve independence, to manage cardiac diseases, and to prevent recurrences. This study aims to investigate the characteristics of independent walking after cardiovascular surgery. We conducted a retrospective cohort study in patients who underwent cardiovascular surgeries (total of 567 patients): 153 in the coronary artery bypass grafting (CABG) group, 312 in the heart valve surgery group, and 102 in the aortic surgery group. We evaluated the effect of each surgery group on the cardiac rehabilitation (CR) progression. The factors associated with independent walking were age, renal diseases, intensive care unit (ICU) length of stay, and post-operative respiratory complications in the CABG group. In the heart valve surgery group, the factors were New York Heart Association functional classification, renal and respiratory diseases, ICU length of stay, duration of mechanical ventilatory support, and post-operative cardiovascular and respiratory complications. In the aortic surgery group, these were ICU length of stay and acute kidney injury. The CR progression in patients who underwent aortic surgery was significantly longer than those who underwent CABG and heart valve surgery (p < 0.001). New intervention strategies are needed for patients with prolonged ICU stays.

Effect of Living Environment Factors on Quality of Life in Patients With Chronic Thromboembolic Pulmonary Hypertension After Completion of Balloon Pulmonary Angioplasty　- A Cross-Sectional Study.

Background: This study investigated factors related to quality of life (QoL) in patients with chronic thromboembolic pulmonary hypertension who completed balloon pulmonary angioplasty (BPA). Methods and Results: Patient QoL and living environment after BPA were evaluated prospectively using the 5-level EQ-5D questionnaire and International Physical Activity Questionnaire Environmental Module (IPAQ-E), respectively. Patients were mailed copies of both surveys. In addition, we reviewed patient charts and collected retrospective clinical data. Relationship between the clinical data and QoL and environmental living factors were investigated. Of the 33 subjects mailed the surveys, sufficient responses were obtained from 22 (71%). Spearman's rank correlation coefficient showed that psychiatric disorders (r=-0.6865, P<0.01) and IPAQ-E Question 5 (r=0.5192, P=0.02), Question 6 (r=0.5265, P=0.02), and Question 13 (r=0.4552, P=0.04) were significantly correlated with EQ-5D scores after BPA. Conclusions: A living environment that was difficult to walk around was associated with a worse QoL. A multidisciplinary approach will be required to improve QoL even after completion of BPA treatment.

Impact of sarcopenia on the progress of cardiac rehabilitation and discharge destination after cardiovascular surgery.

[Purpose] To investigate the factors that affect the progress of cardiac rehabilitation, length of stay in the hospital, and discharge destination after cardiovascular surgery. [Participants and Methods] This was a prospective observational study. Sixty-seven patients scheduled to undergo open-heart surgery were included in the study. We evaluated physical and psychiatric functions pre- and post-surgery. Sarcopenia was defined as a short physical performance battery score of <9.5. [Results] Sarcopenia was a significant factor of delay of the day of the first rehabilitation, independence in 100-m walking, and exercise training at the rehabilitation gym. Comparisons between pre- and post-surgery were performed in the sarcopenia group. No significant decreases in physical and psychiatric functions were found. The discharge transfer rate was significantly different between the sarcopenia and non-sarcopenia groups. Sarcopenia and the decline in balance score significantly correlated with discharge transfer. [Conclusion] Cardiac rehabilitation can achieve recovery of physical and psychiatric functions even in patients with sarcopenia; however, the discharge transfer rate among the patients with sarcopenia was high. Improving balance ability may result in early home discharge.

Rehabilitation progress after lower-extremity bypass surgery in patients with peripheral arterial disease with different occlusive lesions.

[Purpose] To examine the differences in rehabilitation progress after lower-extremity bypass surgery for peripheral arterial disease (PAD) depending on the occlusive lesions. [Participants and Methods] This was a retrospective study. We included 50 patients (61 limbs; 38 males and 12 females; mean age, 73 years) who underwent lower-extremity bypass surgery for Fontaine stage 2-3 PAD. The patients were assigned to the aortoiliac (A-I) group (n=23), femoropopliteal (F-P) group (n=18), and below-knee group (n=9). We evaluated the postoperative rehabilitation progress and length of hospital stay of these groups. [Results] The postoperative ankle-brachial pressure index (ABI) of the A-I group was significantly lower than that of the F-P group, although there were no differences before surgery. The progress of rehabilitation and the length of hospitalization showed no significant differences among the three groups. The postoperative date of independent walking was significantly later in the presence of complications than in the absence of complications. [Conclusion] The progress of rehabilitation after lower-extremity bypass surgery did not differ depending on the occlusive lesions, and patients may acquire independent walking ability in approximately 5 days in the absence of postoperative complications.

Performance of a deep learning-based identification system for esophageal cancer from CT images.

BACKGROUND: Because cancers of hollow organs such as the esophagus are hard to detect even by the expert physician, it is important to establish diagnostic systems to support physicians and increase the accuracy of diagnosis. In recent years, deep learning-based artificial intelligence (AI) technology has been employed for medical image recognition. However, no optimal CT diagnostic system employing deep learning technology has been attempted and established for esophageal cancer so far. PURPOSE: To establish an AI-based diagnostic system for esophageal cancer from CT images. MATERIALS AND METHODS: In this single-center, retrospective cohort study, 457 patients with primary esophageal cancer referred to our division between 2005 and 2018 were enrolled. We fine-tuned VGG16, an image recognition model of deep learning convolutional neural network (CNN), for the detection of esophageal cancer. We evaluated the diagnostic accuracy of the CNN using a test data set including 46 cancerous CT images and 100 non-cancerous images and compared it to that of two radiologists. RESULTS: Pre-treatment esophageal cancer stages of the patients included in the test data set were clinical T1 (12 patients), clinical T2 (9 patients), clinical T3 (20 patients), and clinical T4 (5 patients). The CNN-based system showed a diagnostic accuracy of 84.2%, F value of 0.742, sensitivity of 71.7%, and specificity of 90.0%. CONCLUSIONS: Our AI-based diagnostic system succeeded in detecting esophageal cancer with high accuracy. More training with vast datasets collected from multiples centers would lead to even higher diagnostic accuracy and aid better decision making.

Association of lower extremity function with nutritional status and number of drugs in patients with chronic heart failure.

OBJECTIVE: This study was performed to investigate the physical performance parameters, including lower extremity function parameters, that may be risk factors for falls in patients with chronic heart failure. METHODS: Seventy patients with stable chronic heart failure were included in this retrospective cross-sectional study. The five-repetition sit-to-stand test (5STS) time, Controlling Nutritional Status (CONUT) score, and number of drugs were assessed. RESULTS: Simple linear regression analysis revealed that the 5STS time was positively correlated with age, the CONUT score, and the number of drugs but was negatively associated with the handgrip force, quadriceps force, and quadriceps muscle thickness. Multiple linear regression analysis showed a significant association between the 5STS time and the CONUT score, quadriceps force, and number of drugs. CONCLUSION: The muscle strength, nutritional status, and number of drugs should be evaluated to prevent lower extremity weakness in patients with stable chronic heart failure.

Corticosteroids are associated with reduced skeletal muscle function in interstitial lung disease patients with mild dyspnea.

BACKGROUND: Interstitial lung diseases (ILDs) patients receiving steroid treatment tend to be immobilized by dyspnea and muscle weakness as the disease progresses. We therefore expected that steroid treatment for ILDs would have a greater effect on muscle function under severe dyspnea. To test this hypothesis, we evaluated whether the effect of corticosteroid treatment on peripheral muscle force and exercise capacity varied according to patients' dyspnea severity. METHODS: In this retrospective cross-sectional study of 87 ILD patients enrolled between 2008 and 2017, quadriceps force (QF), handgrip force (HF), and 6-min walk distance (6 MWD) were compared between a low (grades 0-2) and a high (grades 3-4) modified-Medical Research Council (mMRC) dyspnea scale score group. RESULTS: In patients with lower levels of dyspnea, corticosteroid treatments were associated with lower QF and HF (20.0 vs. 30.0 kgf, p = 0.01; 22.5 vs. 28.4 kgf, p = 0.03, respectively) values; however, no significant differences were observed between the corticosteroid and control subgroups in the high mMRC group (QF: 18.5 vs. 17.3 kgf, p = 0.64; HF: 21.0 vs. 17.1 kgf, p = 0.24, respectively). Analysis of covariance indicated that both corticosteroid treatment and mMRC dyspnea scale interacted with QF, HF, and 6 MWD. The effects of the corticosteroid treatment varied according to the level of dyspnea (interaction ß = 7.52, p = 0.034; interaction ß = 8.78, p = 0.048; interaction ß = 131.08, p < 0.001). CONCLUSIONS: Muscle weakness and exercise capacity in ILD patients in the low mMRC group were associated with corticosteroid treatment.

The Relationship between Circulating Polyunsaturated Fatty Acid Levels and Exercise Responses of Patients with Non-ischemic Heart Failure.

Objective Polyunsaturated fatty acids (PUFAs) are associated with heart failure (HF) as well as coronary artery disease. However, little is known about the relationships between PUFAs and the exercise responses of patients with HF. We evaluated the relationships between PUFAs and the parameters of cardiopulmonary exercise tests (CPETs) in patients with non-ischemic HF. Methods Fifty patients with stable non-ischemic HF underwent CPETs at our hospital. Data were analyzed to evaluate the relationships between PUFAs and echocardiographic findings as well as CPET and other test parameters. Results Correlations were significant and negative between dihomo-γ-linolenic acid (DGLA) + arachidonic acid (AA) and minute ventilation versus carbon dioxide production (VE/VCO2) slope, and positive between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and VE/VCO2 slope. A multivariate regression analysis selected DGLA+AA and AA as independent predictors of VE/VCO2 slope. However, eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) were not significantly correlated with the CPET parameters. Conclusion Low levels of circulating DGLA+AA and AA among PUFAs were associated with decreased exercise responses in patients with stable non-ischemic HF. These findings suggest that high levels of omega-6 PUFAs may improve the clinical outcomes of patients with non-ischemic HF via their effects on exercise responses.