SARS-CoV-2 spike receptor-binding domain is internalized and promotes protein ISGylation in human induced pluripotent stem cell-derived cardiomyocytes.

Although an increased risk of myocarditis has been observed after vaccination with mRNA encoding severe acute respiratory syndrome coronavirus 2 spike protein, its underlying mechanism has not been elucidated. This study investigated the direct effects of spike receptor-binding domain (S-RBD) on human cardiomyocytes differentiated from induced pluripotent stem cells (iPSC-CMs). Immunostaining experiments using ACE2 wild-type (WT) and knockout (KO) iPSC-CMs treated with purified S-RBD demonstrated that S-RBD was bound to ACE2 and internalized into the subcellular space in the iPSC-CMs, depending on ACE2. Immunostaining combined with live cell imaging using a recombinant S-RBD fused to the superfolder GFP (S-RBD-sfGFP) demonstrated that S-RBD was bound to the cell membrane, co-localized with RAB5A, and then delivered from the endosomes to the lysosomes in iPSC-CMs. Quantitative PCR array analysis followed by single cell RNA sequence analysis clarified that S-RBD-sfGFP treatment significantly upregulated the NF-kß pathway-related gene (CXCL1) in the differentiated non-cardiomyocytes, while upregulated interferon (IFN)-responsive genes (IFI6, ISG15, and IFITM3) in the matured cardiomyocytes. S-RBD-sfGFP treatment promoted protein ISGylation, an ISG15-mediated post-translational modification in ACE2-WT-iPSC-CMs, which was suppressed in ACE2-KO-iPSC-CMs. Our experimental study demonstrates that S-RBD is internalized through the endolysosomal pathway, which upregulates IFN-responsive genes and promotes ISGylation in the iPSC-CMs.

Modeling Reduced Contractility and Stiffness Using iPSC-Derived Cardiomyocytes Generated From Female Becker Muscular Dystrophy Carrier.

Study investigators encountered a female Becker muscular dystrophy (BMD) carrier with advanced heart failure (HF) and identified a stop-gain variant in procollagen-lysine, 2-oxoglutarate 5-dioxygenase 3 (PLOD3) as a potential second-hit variant. Isogenic induced pluripotent stem cells (iPSCs) with dominant expression of WT-DMD, Δ45-48-DMD, or Δ45-48-DMD with corrected PLOD3 variant were established. Microforce testing using 3-dimensional self-organized tissue rings (SOTRs) generated from iPSC-derived cardiomyocytes (iPSC-CMs) demonstrated that correction of the heterozygous PLOD3 variant did not improve the reduced force, but it significantly recovered the reduced stiffness in Δ45-48-DMD SOTRs. Correction of the PLOD3 variant restored collagen synthesis in iPSC-CMs. Our findings revealed the pathogenesis underlying advanced HF in a female BMD carrier.

Impact of intravascular ultrasound parameters and platelet reactivity on primary patency after drug-coated balloon angioplasty for femoropopliteal artery disease.

Although the superiority of DCBs to uncoated balloon angioplasty for the treatment of femoropopliteal (FP) lesions has been demonstrated, the association of clinical factors, including anatomical features evaluated by intravascular ultrasound (IVUS) and platelet reactivity, with the loss of patency has not been systematically studied. The current prospective, observational study enrolled 160 consecutive patients (male 67.5%, mean age 74.7 ± 9.7 years) with 213 FP lesions treated with DCBs under IVUS evaluation. The platelet reactivity was measured in P2Y12 reaction units for all of the patients at the DCB treatment. The primary end point was primary patency at 12 months, while the secondary end points were freedom from target lesion revascularization (TLR), all-cause death, major target limb amputation and bleeding events at 12 months. Mean lesion length was 11.9 ± 9.4 cm and 34 (16.0%) were chronic total occlusions (CTOs). Thirty-four (16.0%) were severely calcified lesions. Primary patency by Kaplan-Meier estimate was 79.2% at 12 months, while the 12-month freedom from TLR, all-cause death and bleeding events were observed in 89.1%, 93.4% and 97.4%, respectively. There were no major target limb amputations through 12 months. Multivariate analysis showed that subintimal angioplasty for CTO lesions was a sole risk factor for loss of 12-month primary patency, while other IVUS parameters and platelet reactivity were not.

Multiplexed measurement of cell type-specific calcium kinetics using high-content image analysis combined with targeted gene disruption.

Kinetic analysis of intracellular calcium (Ca2+) in cardiomyocytes is commonly used to determine the pathogenicity of genetic mutations identified in patients with dilated cardiomyopathy (DCM). Conventional methods for measuring Ca2+ kinetics target whole-well cultured cardiomyocytes and therefore lack information concerning individual cells. Results are also affected by heterogeneity in cell populations. Here, we developed an analytical method using CRISPR/Cas9 genome editing combined with high-content image analysis (HCIA) that links cell-by-cell Ca2+ kinetics and immunofluorescence images in thousands of cardiomyocytes at a time. After transfecting cultured mouse cardiomyocytes that constitutively express Cas9 with gRNAs, we detected a prolonged action potential duration specifically in Serca2a-depleted ventricular cardiomyocytes in mixed culture. To determine the phenotypic effect of a frameshift mutation in PKD1 in a patient with DCM, we introduced the mutation into Cas9-expressing cardiomyocytes by gRNA transfection and found that it decreases the expression of PKD1-encoded PC1 protein that co-localizes specifically with Serca2a and L-type voltage-gated calcium channels. We also detected the suppression of Ca2+ amplitude in ventricular cardiomyocytes with decreased PC1 expression in mixed culture. Our HCIA method provides comprehensive kinetic and static information on individual cardiomyocytes and allows the pathogenicity of mutations to be determined rapidly.

Human-Induced Pluripotent Stem Cell-Derived Cardiomyocyte Model for TNNT2 Δ160E-Induced Cardiomyopathy.

BACKGROUND: The Δ160E mutation in TNNT2, which encodes troponin T, is a rare pathogenic variant identified in patients with hypertrophic cardiomyopathy and is associated with poor prognosis. Thus, a convenient human model recapitulating the pathological phenotype caused by TNNT2 Δ160E is required for therapeutic development. METHODS: We identified a heterozygous in-frame deletion mutation (c.478_480del, p.Δ160E) in TNNT2 in a patient with familial hypertrophic cardiomyopathy showing progressive left ventricular systolic dysfunction, leading to advanced heart failure. To investigate the pathological phenotype caused by Δ160E, we generated a set of isogenic induced pluripotent stem cells carrying the heterozygous Δ160E, homozygously corrected or homozygously introduced Δ160E using genome editing and differentiated them into cardiomyocytes (Hetero-Δ160E-, wild type-, and Homo-Δ160E-induced pluripotent stem cells [iPSC]-derived cardiomyocytes [iPSC-CMs]). RESULTS: Hetero-Δ160E-iPSC-CMs exhibited prolonged calcium decay, relaxation impairment, and hypertrophy compared to wild type-iPSC-CMs. Notably, these phenotypes were further exacerbated in Homo-Δ160E-iPSC-CMs. Overexpression of R-GECO-fused Δ160E mutant troponin T prolonged decay time and time to peak of the myofilament-localized calcium transient in iPSC-CMs, indicating that sarcomeric calcium retention with Δ160E may affect intracellular calcium concentration. High-content imaging analysis detected remarkable nuclear translocation of NFATc1, especially in Homo-Δ160E-iPSC-CMs, indicating that the Δ160E mutation promotes hypertrophic signaling pathway in a dose-dependent manner. Increased phosphorylation of CaMKIIδ (calcium/calmodulin-dependent protein kinase IIδ) and phospholamban at Thr17 was observed in Homo- and Hetero-Δ160E-iPSC-CMs. Epigallocatechin-3-gallate, a calcium desensitizing compound, shortened prolonged calcium decay and relaxation duration in Δ160E-iPSC-CMs. CONCLUSIONS: Isogenic iPSC-CMs recapitulate the prolonged calcium decay, relaxation impairment, and subsequent calcium-regulated signaling pathways caused by the TNNT2 Δ160E mutation and can serve as a human model for therapeutic development to prevent hypertrophic cardiomyopathy pathology.

Long-Term Outcomes and Clinical Predictors of Mortality Following Occurrence of Stent Thrombosis.

Background Stent thrombosis (ST) remains a significant medical issue. In particular, longer-term mortality and clinical predictors after ST occurrence have yet to be elucidated. Methods and Results This was a multicenter, retrospective, observational study. A total of 187 definite ST cases from January 2008 to December 2017 were enrolled, and the long-term clinical outcomes were investigated. The primary outcome measure was the cumulative mortality after ST occurrence. In addition, independent predictors of mortality were assessed. Among the stent types causing ST, bare-metal stent, first-generation drug-eluting stent, second-generation drug-eluting stent, and third-generation drug-eluting stent comprised 31.0%, 19.3%, 36.9%, and 6.4% of cases, respectively. Median duration from stent implantation to ST was 680.5 (interquartile range, 33.8-2450.5) days. Cumulative mortality was 14.6%, 17.4%, 21.2%, 24.4%, and 33.8% at 1, 2, 3, 5 and 10 years, respectively. The cumulative mortality did not significantly differ by type of stent, and mortality of late ST was higher than that of early ST and very late ST; however, it did not reach statistical significance after the multivariate analysis. Independent predictors of mortality were hemodialysis (hazard ratio [HR], 7.80; 95% CI, 3.07-19.81; P<0.001), culprit lesions in the left main trunk (HR, 8.14; 95% CI, 1.71-38.75; P=0.008), culprit lesions in the left coronary artery (HR, 2.77; 95% CI, 1.10-6.96; P=0.030), and peak creatine kinase (HR, 1.017; 95% CI, 1.011-1.022; P<0.001). Conclusions The 10-year cumulative mortality after ST reached 33.8%. Close follow-up is thus mandatory for patients with ST, especially with hemodialysis, culprit lesions in the left main trunk and left coronary artery, and high peak creatine kinase.

Modeling reduced contractility and impaired desmosome assembly due to plakophilin-2 deficiency using isogenic iPS cell-derived cardiomyocytes.

Loss-of-function mutations in PKP2, which encodes plakophilin-2, cause arrhythmogenic cardiomyopathy (AC). Restoration of deficient molecules can serve as upstream therapy, thereby requiring a human model that recapitulates disease pathology and provides distinct readouts in phenotypic analysis for proof of concept for gene replacement therapy. Here, we generated isogenic induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) with precisely adjusted expression of plakophilin-2 from a patient with AC carrying a heterozygous frameshift PKP2 mutation. After monolayer differentiation, plakophilin-2 deficiency led to reduced contractility, disrupted intercalated disc structures, and impaired desmosome assembly in iPSC-CMs. Allele-specific fluorescent labeling of endogenous DSG2 encoding desmoglein-2 in the generated isogenic lines enabled real-time desmosome-imaging under an adjusted dose of plakophilin-2. Adeno-associated virus-mediated gene replacement of PKP2 recovered contractility and restored desmosome assembly, which was sequentially captured by desmosome-imaging in plakophilin-2-deficient iPSC-CMs. Our isogenic set of iPSC-CMs recapitulates AC pathology and provides a rapid and convenient cellular platform for therapeutic development.

Impact of Longer Hemodialysis Vintage with Higher Serum Phosphorus Level on Clinical Outcomes in Patients with Chronic Limb-Threatening Ischemia Presenting Tissue Loss after Endovascular Therapy.

AIMS: Hemodialysis vintage and serum phosphorus levels adversely affect outcomes in patients on hemodialysis. Whether these factors have a similar prognostic impact on patients who are on hemodialysis and have chronic limb-threatening ischemia (CLTI) has not been systematically studied. We aimed to explore the risk factors, including hemodialysis vintage and serum phosphorus levels, on clinical outcomes after endovascular therapy (EVT) in hemodialysis patients with CLTI. METHODS: The current study rerospectively analyzed 374 hemodialysis patients with CLTI presenting with ischemic tissue loss (age: 72.3±9.0 years, male: 73.3%, diabetes mellitus: 68.2%, Rutherford 5: 75.9%, 6: 24.1%, WIfI stage 4: 50.0%) primarily treated with EVT between April 2007 and December 2016. The primary outcome measure was 1-year amputation-free survival (AFS), while the secondary outcome measure was 1-year wound healing. Predictors for each outcome were evaluated by Cox proportional hazards model. RESULTS: Multivariate analysis significantly associated longer hemodialysis vintages with higher serum phosphorus levels (hazard ratio [HR], 0.599; 95% confidence interval [CI], 0.394-0.910; p=0.016) with 1-year AFS. Longer vintages for hemodialysis with higher serum phosphorus levels were marginally, but not significantly, associated with 1-year wound healing. (HR, 0.684; 95% CI, 0.467-1.000; p=0.050). CONCLUSION: Longer hemodialysis vintages with higher serum phosphorus levels adversely affect outcomes after EVT for hemodialysis patients with CLTI presenting with ischemic tissue loss.

Effect of Rehabilitation Nutrition on a Post-Acute Severe COVID-19 Patient: A Case Report.

Coronavirus disease 2019 (COVID-19) may lead to post-acute physical function deterioration due to intensive-care-unit-acquired weakness-related sarcopenia and dyspnea. Limited reports have examined the effects of rehabilitation and nutritional therapy on patients with post-acute COVID-19. We present the case of a 67-year-old man, who was admitted for the treatment of post-acute severe COVID-19, who benefited from rehabilitation nutrition. When the patient's condition stabilized, sarcopenia and malnutrition were observed, and rehabilitation nutrition was implemented. The physical therapist implemented a program focused mainly on resistance training and aerobic exercise, and the dietitian provided oral nutritional supplements and hospital food that met the patient's energy and protein intake requirements. Comparing the initial evaluations with those at discharge, factors affecting nutritional status, such as body mass index and skeletal muscle mass index, and physical functions, such as grip strength and walking speed, and dyspnea, had improved. The patient was discharged and returned to work. This case suggests improvements in the nutritional status and physical functions of post-acute severe COVID-19 patients by interventions following rehabilitation nutrition.

Effects of Early Physical Therapist-supervised Walking on Clinical Outcomes after Liver Resection: Propensity Score Matching Analysis.

OBJECTIVE: The study aimed to demonstrate the significance of early postoperative physical therapy interventions on clinical outcomes by determining the influence of the distance walked under the supervision of a physical therapist in the early postoperative period after liver cancer. METHODS: All consecutive patients who underwent surgery for liver cancer between April 2018 and March 2020 were eligible for enrollment in the study. The total walking distance during physical therapy till the third postoperative day was examined. The clinical outcomes comprised duration of postoperative hospital stay, time to independent walking, and occurrence of postoperative complications. For data analysis, the patients were divided into two groups: those who walked more than the median total distance (the long-distance group) and those who walked less than the median distance (the short-distance group). We used propensity score matching to match the background characteristics between the groups. RESULTS: Of the 65 patients who were eligible, 14 patients were included in the two groups each, after matching. The long-distance walking group had a significantly shorter hospital stay (9.0 days vs. 11.0 days, p=0.008) and a shorter time to independent walking (3.5 days vs. 7.5 days, p=0.019) than the short-distance walking group. There were no significant differences in postoperative complications between the two groups (7.1% vs. 42.8%, p=0.08). CONCLUSION: In the early postoperative period after liver cancer surgery, increasing the walking distance under the supervision of a physical therapist is important for improving clinical outcomes. Further prospective studies are needed to confirm the findings of this study.

Effect of Rehabilitation Nutrition Care Process on Physical Function in Lung Cancer Cachexia: A Case Report.

OBJECTIVES: Patients with cancer cachexia have poor adherence to treatment, which affects their prognosis. Currently, there are many studies on the effects of rehabilitation on cancer cachexia, but there is a lack of evidence on the effects of nutrition therapy alone or in combination with rehabilitation and nutrition therapy. This article describes a case in which rehabilitation nutrition care process was effective in a patient with lung cancer who developed cancer cachexia. METHODS: A 68-year-old woman was hospitalized for treatment of lung adenocarcinoma. The patient had moderate malnutrition, sarcopenia, and cachexia at the time of admission, so the authors intervened according to rehabilitation nutrition care process. The physiotherapist mainly prescribed resistance training and aerobic exercise, 40-60 minutes a day, 5-6 days a week. And the dietitian provided oral nutritional supplements (100 kcal, branched-chain amino acid: 3.0 g) in addition to hospital food and adjusted the patient's energy intake to 26.96-33.05 kcal/kg/day and protein intake to 1.07-1.14 g/kg/day. OUTCOMES: Comparing the initial evaluation with the discharge, nutritional status, such as body mass index and skeletal muscle mass, and physical functions, such as maximum grip strength, gait speed, and functional independence measure (motor items), were improved. CONCLUSIONS: Rehabilitation nutrition care process-based interventions may improve nutritional status and physical functions more than exercise therapy alone in patients with lung cancer cachexia.

Improved crossability with novel cutting balloon versus scoring balloon in the treatment of calcified lesion.

Cutting balloons and scoring balloons are commonly used for the preparation of calcified lesion. However, problems with crossability occasionally limit the use of cutting balloons. We prospectively selected 173 calcified lesions treated using a novel cutting balloon (Wolverine™, C group). As control, we retrospectively analyzed 146 calcified lesions treated using a scoring balloon (Lacrosse NSE ALPHA™, S group). Either intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used by the operator's discretion. The primary outcome was delivery success, which was defined as successful passage to the target lesion immediately after IVUS or OCT evaluation. The secondary outcome was acute cross-sectional area (CSA) gain, which was defined as post-interventional minimum stent area minus pre-procedural minimum lumen area. A multivariate analysis evaluated the independent predictors for delivery success. The delivery success rate was significantly higher in the C group versus the S group (90.8% versus 79.5%, P = 0.006). However, the acute CSA gain was similar between the two groups (IVUS: 3.2 ± 1.8 mm2 versus 3.4 ± 1.9 mm2, P = 0.53; OCT: 3.6 ± 1.4 mm2 versus 4.1 ± 1.9 mm2, P = 0.11). Usage of cutting balloon was an independent predictor for delivery success even after the adjustment for the patient and lesion characteristics [odds ratio (OR): 2.72 (95% confidence interval 1.38-5.33), P = 0.004] as well as the procedural characteristics [OR: 2.34 (1.15-4.86), P = 0.018]. Novel cutting balloons demonstrated better crossability and similar acute CSA gain compared with scoring balloons in calcified lesion.

Risk Stratification for 2-Year Mortality in Patients with Chronic Limb-Threatening Ischemia Undergoing Endovascular Therapy.

AIM: The latest Global Vascular Guidelines (GVG) recommend assessing the 2-year mortality risk in patients with chronic limb-threatening ischemia (CLTI) before revascularization. This study aimed to reveal whether the Wound, Ischemia and foot Infection (WIfI) classification, developed originally as a risk assessment tool for limb prognosis, would be useful in predicting the 2-year mortality risk in patients with CLTI in the era of GVG and WIfI. METHODS: We retrospectively analyzed 849 patients with CLTI who were primarily treated with endovascular therapy (EVT) between April 2010 and December 2016. The impact of baseline characteristics, including the WIfI classification on mortality risk, was investigated using the Cox proportional hazards regression model. RESULTS: During a mean follow-up of 19.3 months, 243 deaths were observed. The 2-year mortality rate was 32.3%. Multivariate analysis demonstrated that WIfI classification stages (p=0.037), in addition to male sex (p=0.010), age (p＜0.001), non-ambulatory status (p＜0.001), body mass index (p=0.002), and hemodialysis (p＜0.001), were independent predictors for an increased risk of mortality, while the Rutherford classification was not. CONCLUSIONS: WIfI classification stages were independently associated with mortality risk in patients with CLTI undergoing EVT, while the Rutherford classification was not. The WIfI classification would be a practical tool for planning the revascularization strategy in CLTI treatment.

Angioscopic assessments and clinical outcomes one year after polymer-free biolimus A9-coated coronary stent implantation.

BACKGROUND: Polymer-free biolimus A9-coated coronary stent (DCS) has novel features which lead to the expectation of better arterial healing. However, comparisons of intravascular status between DCS and drug-eluting stents (DES), and robust real-word clinical assessments of DCS have been lacking to date. METHODS: From September 2017 to September 2018, we evaluated the intra-vascular status of 74 DCS implanted in 55 lesions from 43 patients using coronary angioscopy (CAS) approximately one year after implantation from a cohort of 219 lesions in 158 patients. We set 239 second-generation durable-polymer DES (DP-DES) implanted in 211 lesions from 180 patients from a cohort of 2652 lesions in 1914 patients as the control. Angioscopic images were analyzed to determine (1) the dominant degree of neointimal coverage (NIC) over the stent; (2) the heterogeneity of NIC; (3) yellow color grade of the stented segment; and (4) the presence of intra-stent thrombus. The primary outcome was the incidence of thrombus and secondary outcomes were the other CAS findings, and the 1-year clinical outcomes which included target lesion revascularization (TLR) and major adverse cardiac events (MACE). To minimize inter-group differences in baseline characteristics, propensity score matching was performed for clinical outcomes. RESULTS: Incidence of thrombus adhesion was similar in DCS and DP-DES groups (28.4% versus 22.6%, p=0.31). However, the dominant NIC grade was significantly higher in DCS (p<0.001), while NIC was more heterogeneous in DCS than in DP-DES (p=0.001). Maximum yellow color grade was similar (p=0.22). After propensity score matching, 202 lesion pairs from 146 patient pairs were retained for analysis. The cumulative incidence of TLR (4.6% versus 3.8%, p=0.38) and MACE (11.6% versus 11.7%, p=0.84) was similar for DCS and DP-DES. CONCLUSIONS: DCS showed thrombus adhesion and clinical outcomes at 1 year similar to DP-DES. DCS can thus be used with similar safety and efficacy as DP-DES.

Comparison of prognosis and safety of pacemaker implantation in patients aged less than or 85 years and older.

PURPOSE: Cardiac conduction disturbance necessitating pacemaker implantation is common among elderly patients. However, patients often have comorbidities and increased frailty which may result in limited life prognosis and a high rate of procedure-related complications. We evaluated pacemaker implantation in older patients by comparing life prognosis and complication rate in patients aged ≥ and < 85 years. METHODS: We retrospectively enrolled 262 consecutive patients who underwent initial pacemaker implantation for bradycardia (age, 77 ± 10 years old; male, 132 (50%); dual chamber pacemaker, 222 (85%) patients). Acute and long-term outcomes were compared between patients aged ≥ 85 and < 85 years. Primary outcome was a composite of all-cause death and severe procedure-related complications. RESULTS: Seven (14%) patients aged ≥ 85 years (n = 50; 19%) were non-ambulatory. During 2-year follow-up, primary outcome (death or severe complication) occurred in 47 (18%). Freedom from primary outcome was similar between age groups (81.6% versus 80.8%; p = 0.98). Freedom from all-cause death and from severe complication in the study period were also similar (all-cause death, 91.6% versus 88.7%, p = 0.70; severe complication, 89.7% versus 91.5%, p = 0.75). On multivariate analysis, sick sinus syndrome (hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.1-6.4, p = 0.03), immunosuppressant use (HR 21 (95% CI 3.3-134), p < 0.01), and high C-reactive protein (HR 1.5 (95% CI 1.2-1.9), p < 0.01) were independent predictors of primary outcome. CONCLUSIONS: Life prognosis and severe complication rates after pacemaker implantation were similar between patients aged ≥ and < 85 years.

Enhanced O-GlcNAcylation Mediates Cytoprotection under Proteasome Impairment by Promoting Proteasome Turnover in Cancer Cells.

The proteasome is a therapeutic target in cancer, but resistance to proteasome inhibitors often develops owing to the induction of compensatory pathways. Through a genome-wide siRNA screen combined with RNA sequencing analysis, we identified hexokinase and downstream O-GlcNAcylation as cell survival factors under proteasome impairment. The inhibition of O-GlcNAcylation synergistically induced massive cell death in combination with proteasome inhibition. We further demonstrated that O-GlcNAcylation was indispensable for maintaining proteasome activity by enhancing biogenesis as well as proteasome degradation in a manner independent of Nrf1, a well-known compensatory transcription factor that upregulates proteasome gene expression. Our results identify a pathway that maintains proteasome function under proteasome impairment, providing potential targets for cancer therapy.

Impact of the Temporal Relationship Between Atrial Fibrillation and Heart Failure on Prognosis After Ablation.

BACKGROUND: The purpose of this study was to elucidate the effect of the temporal relationship between atrial fibrillation (AF) and heart failure (HF) on clinical outcomes after catheter ablation.Methods and Results:We included 129 consecutive patients with AF and HF who underwent catheter ablation in hospital from December 2014 to September 2017. The patients were divided into 2 groups based on the temporal relationship between AF and HF. Group 1 consisted of 42 patients with AF following HF while Group 2 consisted of 87 patients with AF preceding HF or those who developed both of them simultaneously at the timing of first visit to a doctor. The primary endpoint was a composite of death and hospitalization due to HF during a 2-year follow-up. AF recurrence was more common in Group 1 (45% vs. 23%; hazard ratio [HR], 2.49; 95% confidence interval [CI], 1.25-4.94; P=0.009). Death and HF hospitalization were more frequent in Group 1 (19 [45%], 6 [7%] patients, respectively, P<0.0001). After adjustment for several covariates, patients in Group 1 were independently associated with poorer outcomes after AF ablation (HR, 8.66; 95% CI, 2.942-5.5; P<0.0001). CONCLUSIONS: Adverse clinical outcomes of death, HF hospitalization and AF recurrence were more frequent in patients with AF following HF than in those with AF preceding HF.

Additional Low-Voltage-Area Ablation in Patients With Paroxysmal Atrial Fibrillation: Results of the Randomized Controlled VOLCANO Trial.

Background The efficacy of low-voltage-area (LVA) ablation has not been well determined. This study aimed to investigate the efficacy of LVA ablation in addition to pulmonary vein isolation on rhythm outcomes in patients with paroxysmal atrial fibrillation (AF). Methods and Results VOLCANO (Catheter Ablation Targeting Low-Voltage Areas After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation Patients) trial included paroxysmal AF patients undergoing initial AF ablation. Of 398 patients in whom a left atrial voltage map was obtained after pulmonary vein isolation, 336 (85%) had no LVA (group A). The remaining 62 (15%) patients with LVAs were randomly allocated to undergo LVA ablation (group B, n=30) or not (group C, n=32) in a 1:1 fashion. Primary end point was 1-year AF-recurrence-free survival rate. No adverse events related to LVA ablation occurred. Procedural (124±40 versus 95±33 minutes, P=0.003) and fluoroscopic times (29±11 versus 24±8 minutes, P=0.034) were longer in group B than group C. Patients with LVAs demonstrated lower AF-recurrence-free survival rates (88%) than those without LVA (B, 57%, P<0.0001; C, 53%, P<0.0001). However, LVA ablation in addition to pulmonary vein isolation did not impact AF-recurrence-free survival rate (group B versus C, P=0.67). Conclusions The presence of LVA was a strong predictor of AF recurrence after pulmonary vein isolation in patients with paroxysmal AF. However, LVA ablation had no beneficial impact on 1-year rhythm outcomes. Registration URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000023403.

Infrapopliteal Anatomic Severity and Delayed Wound Healing in Patients With Chronic Limb-Threatening Ischemia in the Era of the Global Limb Anatomic Staging System.

Purpose: To investigate the prognostic impact of infrapopliteal (IP) artery anatomic severity according to the Global Limb Anatomic Staging System (GLASS) on delayed wound healing in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This study retrospectively analyzed 639 limbs with tissue loss in 484 CLTI patients (mean age 74±10 years; 300 men) presenting IP lesions treated with endovascular therapy between April 2010 and December 2015. Two-thirds of patients had diabetes (323, 67%) and over half were on hemodialysis (255, 53%). More than a third of the limbs (251, 39%) were classified as clinical stage 4 according to the Wound, Ischemia, and foot Infection (WIfI) system. IP anatomic severity was classified based on preprocedural angiography according to the GLASS. Severity of arterial calcification was assessed using high-intensity fluoroscopy and classified into 3 groups: none (grade 0), unilateral (grade 1), and bilateral (grade 2). Poor below-the-ankle (BTA) runoff was defined as the lack of a pedal arch with 0 to 1-vessel runoff within the dorsal pedis artery and the lateral and medial plantar arteries. The outcome measure was 1-year wound healing. The association of anatomic characteristics with delayed wound healing was evaluated using Cox proportional hazards regression analysis. Outcomes are presented as the adjusted hazard ratio (HR) with 95% confidence interval (CI). Results: During a mean follow-up of 22±19 months, the 1-year cumulative wound healing rate was estimated to be 59.0% (95% CI 54.5% to 63.5%). Multivariable analysis demonstrated independent associations between delayed wound healing and IP calcification grade (HR 1.24, 95% CI 1.02 to 1.50, p=0.027) and poor BTA runoff (HR 1.39, 95% CI 1.04 to 1.85, p=0.025) but not the GLASS IP grade (HR 0.92, 95% CI 0.82 to 1.14, p=0.21). Conclusion: The current study revealed that IP arterial calcification and poor BTA runoff were significantly associated with delayed wound healing, whereas the GLASS was not predictive of wound healing.

A saline contrast-enhanced echocardiography-guided approach to cryoballoon ablation.

BACKGROUND: Pulmonary vein isolation (PVI) with a cryoballoon usually uses iodinated contrast medium for confirmation of venous occlusion. We hypothesized that an alternative to angiography with iodinated contrast, saline bolus-enhanced echocardiography with the microbubbles formed in situ, could be used to assess venous occlusion. We sought to assess the efficacy and safety of the contrast-enhanced intracardiac echocardiographic (ICE) approach. METHODS: Thirty-four consecutive patients without iodine sensitivity or renal insufficiency were studied to assess the accuracy of ICE-guided PV occlusion underwent both angiographic guidance and ICE guidance (validation group). Twenty consecutive patients with paroxysmal atrial fibrillation (AF) and contraindications to iodinated contrast medium (ICE-guided group) underwent PV occlusion and ablation with ICE guidance alone. Procedural results and clinical outcomes were compared with those of 245 control patients undergoing PVI by the conventional angiographic method (control group). RESULTS: In the validation group, ICE-guided PV occlusion was as effective as angiography-guided PV occlusion. In the ICE-guided group, two patients required touch-up ablation using a radiofrequency ablation catheter with fluoroscopic guidance. Procedure time, radiation exposure, and requirements for touch-up ablation were similar between the ICE-guided group and the control group. In patients requiring only PVI, the ICE-guided approach involved significantly less radiation exposure than the conventional approach. There was no significant difference in atrial fibrillation (AF)-free survival rate between the two groups during a follow-up period of 14 ± 6 months. CONCLUSIONS: An echo-guided approach using saline infusion was effective in terms of avoidance of iodinated contrast use and radiation exposure.