Impact of the Barthel Index Score and Prognosis on Patients Undergoing Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement.

BACKGROUND: Few studies have compared the Barthel Index (BI) score and postoperative outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). We aimed to examine the relationship between the BI score and postoperative outcomes in patients who underwent TAVR and SAVR.Methods and Results: The study included patients who underwent SAVR between January 2014 and December 2022 (n=293) and patients who underwent TAVR between January 2016 and December 2022 (n=312). We examined the risk factors for long-term mortality in the 2 groups. The mean (±SD) preoperative BI score was 88.7±18.0 in the TAVR group and 95.8±12.3 in the SAVR group. The home discharge rate was significantly lower in the SAVR than TAVR group. The BI score at discharge was significantly higher in the SAVR than in TAVR group (86.2 vs. 80.2; P<0.001). Significant risk factors for long-term mortality in the TAVR group were sex (P<0.001) and preoperative hemoglobin level (P=0.008), whereas those in the SAVR group were preoperative albumin level (P=0.04) and postoperative BI score (P=0.02). The cut-off point of the postoperative BI score determined by receiver operating characteristic curve analysis was 60.0. CONCLUSIONS: The BI score at discharge was a significant risk factor for long-term mortality in the SAVR group, with a cut-off value of 60.0.

Left ventricular mass and valve performance after surgical and transcatheter aortic valve replacement: a single-center experience from Japan.

Background: There are few reports on the postoperative left ventricular mass (LVM), aortic valve area (AVA), and pressure gradient (PG) after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in Japan. We aimed to compare the postoperative LVM, AVA, stroke volume (SV), PG, and long-term outcomes between patients undergoing SAVR and TAVR procedures from single center in Japan. Methods: This was a retrospective cohort study. We included 107 patients who underwent simple SAVR between January 2012 and May 2022 (SAVR group, n=107) and 274 who underwent TAVR between January 2016 and May 2022 (TAVR group, n=274). The overall mean follow-up periods was 28.8±25.9 months (median: 24 months; range, 0.03-117 months). Results: The aortic valve mean PG (mmHg) was significantly smaller in the TAVR group than in the SAVR group (P<0.001). The AVA index (cm2/m2) was significantly larger in the TAVR group than in the SAVR group (P<0.001). The SV index (mL/m2) was significantly smaller in the SAVR group than in the TAVR group (P=0.02). The LVM index (LVMI) (g/m2) was significantly smaller in the SAVR group than in the TAVR group (P<0.001). The incidence of mild or higher postoperative paravalvular leak (PVL) and pacemaker implantation were significantly higher in the TAVR group. The 5-year postoperative mortality, re-hospitalization, and major adverse cerebral and cardiovascular events (MACCEs) were significantly better in the SAVR group. Conclusions: The postoperative aortic valve PG, AVA, and SV were better in the TAVR group; however, LVM regression and postoperative outcomes were better in the SAVR group.

Impact of Helicopter Transport on Reperfusion Times and Long-Term Outcomes in Acute Myocardial Infarction Patients in Rural Areas: A Report From the Mie Acute Coronary Syndrome Registry.

OBJECTIVE: Helicopter emergency medical services (HEMS) are effective for time-sensitive conditions, such as stroke and trauma. However, prognostic data on helicopter transport for acute myocardial infarction (AMI) patients are insufficient. METHODS: We registered 2,681 AMI patients in the Mie Acute Coronary Syndrome Registry and enrolled 163 patients from rural areas to HEMS base hospitals with HEMS or ground emergency medical services (GEMS). They were categorized into 4 groups according to the transportation method for interhospital transfer (direct HEMS: n = 52, direct GEMS: n = 54, interhospital HEMS: n = 32, and interhospital GEMS: n = 25). The primary end point was the emergency medical services (EMS) call-to-balloon time. The secondary end point was 2-year major adverse cardiac and cerebrovascular events. RESULTS: The direct HEMS group was younger than the direct GEMS group (P = .029). The EMS call-to-balloon time was shorter in the direct HEMS and interhospital HEMS groups than in each GEMS group (P = .015 and P = .046). The incidence of 2-year major adverse cardiac and cerebrovascular events tended to be lower in both HEMS groups than in each GEMS group. CONCLUSION: Direct HEMS for AMI in rural areas shortens the time from the EMS call to reperfusion when the transport distance is expected to exceed 30 km, which may result in a better patient prognosis. In addition, prehospital diagnostic modalities, such as 12-lead electrocardiography and echocardiography, may shorten the duration from the EMS call to reperfusion.

Remote Management of Pacemaker Patients With Biennial In-Clinic Evaluation: Continuous Home Monitoring in the Japanese At-Home Study: A Randomized Clinical Trial.

BACKGROUND: Current expert consensus recommends remote monitoring for cardiac implantable electronic devices, with at least annual in-office follow-up. We studied safety and resource consumption of exclusive remote follow-up (RFU) in pacemaker patients for 2 years. METHODS: In Japan, consecutive pacemaker patients committed to remote monitoring were randomized to either RFU or conventional in-office follow-up (conventional follow-up) at twice yearly intervals. RFU patients were only seen if indicated by remote monitoring. All returned to hospital after 2 years. The primary end point was a composite of death, stroke, or cardiovascular events requiring surgery, and the primary hypothesis was noninferiority with 5% margin. RESULTS: Of 1274 randomized patients (50.4% female, age 77±10 years), 558 (RFU) and 550 (Conventional follow-up) patients reached either the primary end point or 24 months follow-up. The primary end point occurred in 10.9% and 11.8%, respectively (P=0.0012 for noninferiority). The median (interquartile range) number of in-office follow-ups was 0.50 (0.50-0.63) in RFU and 2.01 (1.93-2.05) in conventional follow-up per patient-year (P<0.001). Insurance claims for follow-ups and directly related diagnostic procedures were 18 800 Yen (16 500-20 700 Yen) in RFU and 21 400 Yen (16 700-25 900 Yen) in conventional follow-up (P<0.001). Only 1.4% of remote follow-ups triggered an unscheduled in-office follow-up, and only 1.5% of scheduled in-office follow-ups were considered actionable. CONCLUSIONS: Replacing periodic in-office follow-ups with remote follow-ups for 2 years in pacemaker patients committed to remote monitoring does not increase the occurrence of major cardiovascular events and reduces resource consumption. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT01523704.

A Decision Tree-Based Survival Analysis of Patients with a History of Inappropriate Implantable Cardioverter-Defibrillator Therapy.

Implantable cardioverter-defibrillators (ICDs) improve survival in patients who are at risk of sudden death. However, inappropriate therapy is commonly given to ICD recipients, and this situation may be associated with an increased risk of death. This study aimed to construct a risk stratification scheme by using decision tree analysis in patients who received inappropriate ICD therapy.Mortality was calculated from a retrospective data analysis of a multicenter cohort involving 417 ICD recipients. Inappropriate therapy was defined as therapy for nonventricular arrhythmias, including sinus tachycardia, supraventricular tachycardia, atrial fibrillation/flutter, oversensing, and lead failure. Inappropriate therapy included antitachycardia pacing, cardioversion, and defibrillation. The prognostic factors were identified by a Cox proportional hazards regression analysis, and we constructed a decision tree.During an average follow-up of 5.2 years, 48 patients (12%) had all-cause death. A multivariate Cox hazard model revealed that the age (hazard ratio [HR] 1.06, P < 0.001), ln B-type natriuretic peptide (BNP) (HR 1.47, P = 0.02), nonsinus rhythm at implantation (HR 2.70, P < 0.05), and inappropriate therapy occurring during sedentary/awake conditions (HR 3.51, P = 0.001) correlated with an increased risk of mortality. An inappropriate therapy due to abnormal sensing (HR 0.16, P = 0.04) decreased the risk of mortality. Furthermore, a decision tree analysis stratified the patients well by using 4 covariates: BNP, activity at the time of inappropriate therapy, mechanism of inappropriate therapy, and baseline rhythm at ICD implantation (log-rank test, P < 0.0001).We identified the predictors of mortality in inappropriate ICD therapy recipients and constructed a risk stratification scheme by using decision tree analysis.

Inappropriate implantable cardioverter defibrillator shocks-incidence, effect, and implications for driver licensing.

PURPOSE: Patients with implantable cardioverter defibrillators (ICDs) have an ongoing risk of sudden incapacitation that may cause traffic accidents. However, there are limited data on the magnitude of this risk after inappropriate ICD therapies. We studied the rate of syncope associated with inappropriate ICD therapies to provide a scientific basis for formulating driving restrictions. METHODS: Inappropriate ICD therapy event data between 1997 and 2014 from 50 Japanese institutions were analyzed retrospectively. The annual risk of harm (RH) to others posed by a driver with an ICD was calculated for private driving habits. We used a commonly employed annual RH to others of 5 in 100,000 (0.005%) as an acceptable risk threshold. RESULTS: Of the 4089 patients, 772 inappropriate ICD therapies occurred in 417 patients (age 61 ± 15 years, 74% male, and 65% secondary prevention). Patients experiencing inappropriate therapies had a mean number of 1.8 ± 1.5 therapy episodes during a median follow-up period of 3.9 years. No significant differences were found in the age, sex, or number of inappropriate therapies between patients receiving ICDs for primary or secondary prevention. Only three patients (0.7%) experienced syncope associated with inappropriate therapies. The maximum annual RH to others after the first therapy in primary and secondary prevention patients was calculated to be 0.11 in 100,000 and 0.12 in 100,000, respectively. CONCLUSIONS: We found that the annual RH from driving was far below the commonly cited acceptable risk threshold. Our data provide useful information to supplement current recommendations on driving restrictions in ICD patients with private driving habits.

Does T wave inversion in lead aVL predict mid-segment left anterior descending lesions in acute coronary syndrome? A retrospective study.

OBJECTIVES: Limited data are available regarding the predictive value of electrocardiographic T wave inversion in lead aVL for mid-segment left anterior descending (MLAD) lesions among patients with acute coronary syndrome (ACS). SETTING: Retrospective single-centre study, using a prospectively-collected coronary angiography database from January 2012 to December 2013. PARTICIPANTS: We included consecutive adult patients with ACS who underwent urgent percutaneous coronary intervention (PCI) within 24 h after arriving at the hospital. We excluded patients who did not undergo an ECG before PCI, patients with proximal MLAD occlusion and patients diagnosed with vasospastic angina. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was MLAD lesion >50%. The other outcome of interest was MLAD lesion as a cause of ACS. First, we evaluated the diagnostic values of T wave inversion in lead aVL regardless of other T wave changes for each outcome. Second, we evaluated the diagnostic values of isolated T wave inversion in lead aVL. RESULTS: Overall, 219 patients were eligible for the analysis. T wave inversion in lead aVL regardless of other T wave changes had a sensitivity of 32.9%, specificity of 48.2%, positive predictive value of 27.6% and negative predictive value of 54.5% for predicting MLAD lesions. Isolated T wave inversion in lead aVL had a sensitivity of 9.8%, specificity of 86.9%, positive predictive value of 30.8% and negative predictive value of 61.7% for predicting MLAD lesions. These diagnostic values did not change materially when focusing on patients with MLAD lesion as the cause. CONCLUSIONS: While T wave inversion in lead aVL regardless of other T wave changes had low diagnostic values for predicting MLAD lesions, isolated T wave inversion in lead aVL had a high specificity. Our inferences underscore the importance of a cautious interpretation of T wave inversion in lead aVL among patients with ACS.

Beat-to-beat T-wave amplitude variability in the risk stratification of right ventricular outflow tract-premature ventricular complex patients.

AIMS: Premature ventricular complexes (PVCs) originating from the right ventricular outflow tract (RVOT) may occasionally trigger monomorphic ventricular tachycardia (MVT), polymorphic ventricular tachycardia (PVT), or ventricular fibrillation (VF). We examined whether an analysis of the ventricular repolarization instability could differentiate PVT/VF triggered by RVOT-PVCs from benign RVOT-PVCs or MVT. METHODS: We evaluated the ventricular repolarization instability as assessed by the beat-to-beat T-wave amplitude variability (TAV) using Holter recordings in patients with RVOT-PVCs but with no structural heart disease. We determined the prematurity index, defined as the ratio of the coupling interval of the first ventricular tachycardia (VT) beat or isolated PVC to the preceding R-R interval just before the VT or isolated PVC in the Holter recordings. The study patients were classified into RVOT-PVCs/MVT (n = 33) and PVT/VF (n = 10). RESULTS: The two groups did not differ with respect to the age, sex, and left ventricular ejection fraction. There was no significant difference in the prematurity index between the two groups (RVOT-PVCs/MVT 0.66 ± 0.16 vs. PVT/VF 0.61 ± 0.13, P = 0.60). The patients with PVT/VF had a significantly larger maximum TAV than those with RVOT-PVCs/MVT (31 ± 13 vs. 68 ± 40 µV, P < 0.001). Patients with a higher than median value of the TAV (33 µV) were at increased risk of PVT/VF vs. those with a lower than median value, after adjusting for the age and sex [9.25 (95% confidence interval: 1.27-19.2); P = 0.03]. CONCLUSIONS: The TAV analysis is a useful measure to identify the subset of usually benign RVOT-PVC/MVT patients prone to PVT/VF.

Prognostic value of serum parathyroid hormone level in acute decompensated heart failure.

BACKGROUND: Secondary hyperparathyroidism develops as a compensatory response to chronic heart failure (HF) and renal failure. The role of parathyroid hormone (PTH) level in acute decompensated HF remains unclear. The aim of this study was therefore to investigate the relationships among mortality, renal function, and serum PTH level in acute decompensated HF patients. METHODS AND RESULTS: A total of 266 consecutive patients admitted for acute decompensated HF without acute coronary syndrome (78±12 years; 48% male) were enrolled. Demographic, clinical, and laboratory characteristics were obtained on admission.During 1-year follow-up, 65 patients (24%) died. Serum PTH level on admission was within the normal range (10-65 pg/ml) in 108 patients (41%), of whom 39 (15%) had low-normal PTH (10-40 pg/ml). On Kaplan-Meier analysis all-cause mortality was significantly higher in patients with low-normal PTH than in those with high-normal (40-65 pg/ml) or high (>65 pg/ml) PTH (log-rank test). On univariate and multivariate Cox regression analysis, low-normal PTH was significantly associated with increased all-cause mortality (unadjusted HR, 2.88; 95% CI: 1.69-4.91; P<0.001; adjusted HR, 3.84; 95% CI: 1.54-9.57; P=0.004). CONCLUSIONS: In patients with acute decompensated HF resulting in hospitalization, low-normal PTH on admission is associated with increased all-cause mortality, regardless of renal function.

Reliability of implantable cardioverter defibrillator home monitoring in forecasting the need for regular office visits, and patient perspective. Japanese HOME-ICD study.

BACKGROUND: Remote monitoring (RM) technology has emerged as a potentially efficient method to manage patients with implantable cardioverter defibrillators (ICDs) or cardiac resynchronization therapy defibrillators (CRT-Ds). This study evaluated the reliability of daily RM in forecasting the need for regular in-hospital follow-ups (RFUs). METHODS AND RESULTS: Two hundred and fifteen patients implanted with Biotronik Lumax devices (142 ICDs, 73 CRT-Ds) were enrolled. RFU was performed at 3, 6, 9, and 12 months after implantation. Immediately before an RFU, the physician forecasted the need for RFU based on RM data (pre-RFU assessment). A completed RFU session was classified as necessary if an action was undertaken potentially influencing patient safety, device therapy, or medication therapy (post-RFU assessment). Overall, 663 pairs of pre- and post-RFU assessments were compared. The number of pre-RFU assessments failing to predict the need for RFU was 38 (5.7%), fulfilling the study hypothesis of 5.0±4.0% (P<0.002; 95% confidence interval: 4.1-7.8%). Judged by an independent committee, the rate of false pre-RFU forecasts with high clinical relevance was 2 (0.3%). RM correctly forecasted non-necessity of 498 scheduled RFUs (75.1%). Patient acceptance of RM was evaluated using a targeted questionnaire. Of 182 interviewed patients, 172 (94.5%) felt security and comfort. CONCLUSIONS: RM-based forecasts appear sufficiently accurate to safely individualize RFU. Most patients have a positive attitude towards RM.

Intra-aortic balloon pump induced dynamic left ventricular outflow tract obstruction and cardiogenic shock after very late stent thrombosis in the left anterior descending coronary artery.

An 81-year-old woman had undergone percutaneus coronary intervention to mid left anterior descending coronary artery with a drug-eluting stent for effort angina pectoris. Although she had remained asymptomatic for 3 years, she developed cardiogenic shock following acute myocardial infarction due to stent thrombosis. Her condition deteriorated despite successful revascularization and an initiation of intra-aortic balloon pump (IABP). Transthoracic echocardiography examination revealed systolic anterior motion of the anterior mitral leaflet which caused severe left ventricular outflow tract obstruction (LVOTO) and moderate mitral regurgitation. Discontinuation of IABP resulted in immediate and complete recovery from cardiogenic shock and echocardiography revealed no LVOTO. These findings may shed new light on the underlying mechanism responsible for deteriorating LVOTO and yield new insights into the assessment and the treatment of cardiogenic shock with dynamic LVOTO.

Ischemia-induced Brugada-type ST-segment alternans and Brugada syndrome.

UNLABELLED: The mechanisms of Brugada-type electrocardiographic (ECG) pattern remain unclear. METHODS: The ST-segment was evaluated during coronary intervention of proximal right coronary artery (RCA). We measured ST-segment elevation with a drug challenge test with a sodium channel blocker. The ST-segment changes were compared with those in true Brugada syndrome. RESULTS: Brugada-type ECG was observed in 6 patients but not in 9 patients during coronary intervention. Five patients demonstrated Brugada-type ST elevation and alternans from coved type to saddleback type during coronary intervention. The patients with ST alternans demonstrated the conus branch occlusion or RV branch occlusion. A drug challenge test developed a significant ST-segment elevation neither in patients with Brugada-type ECG nor in patients without Brugada-type ECG. (0.69±0.48 mv vs. 0.48±0.31 mv, p=NS) There was a significant difference in the ST-segment elevation between patients with Brugada-type ECG during the coronary intervention and patients with true Brugada syndrome (n=5). (0.69±0.48 mv vs. 2.86±0.61 mv, p<0.05). CONCLUSIONS: Ischemia of proximal RCA can masquerade as the Brugada syndrome, ST-segment elevation and alternans. Ischemia of proximal RCA could be one of the different entities showing Brugada-type ECG from true Brugada syndrome.

Synergistic effects of cardiac resynchronization therapy and Bachmann's bundle pacing on heart failure with atrial tachyarrhythmias.

Cardiac resynchronization therapy (CRT) is electrical resynchronization of the ventricles. Bachmann's bundle (BB) pacing is considered to be electrical resynchronization of the atria. Atrial fibrillation (AF) and congestive heart failure (HF) often coexist in the same patient. A 69 year-old man who underwent CRT combined with BB pacing for HF and atrial tachycardias or atrial fibrillation (AF) improved HF symptoms. The combined therapy reduced the number of admissions and occurrence of atrial tachyarrhythmias. It is possible that CRT combined with BB pacing could provide synergistic, beneficial effects on symptoms in patients with HF and AF and hence break a vicious circle.

Advanced atrioventricular block induced by obstructive sleep apnea before oxygen desaturation.

We report a patient with transient advanced atrioventricular (AV) block induced by obstructive sleep apnea (OSA). This 54-year-old man was diagnosed as having severe OSA and AV block with ventricular asystole for more than 6 s during overnight polysomnography, which occurred just from the onset of OSA before oxygen desaturation had occurred. An electrophysiological study revealed normal AV conduction system function and normal His-Purkinje system function. The resolution of OSA with continuous positive airway pressure therapy improved the advanced AV block. Therefore, the bradyarrhythmia was determined to be an OSA-induced AV block that occurred before oxygen desaturation.

Effects of right atrial pacing preference in prevention of paroxysmal atrial fibrillation: Atrial Pacing Preference study (APP study).

BACKGROUND: Several preliminary studies have indicated that atrial pacing can prevent atrial tachyarrhythmias. The suggested mechanisms by which pacing may be effective include suppression of premature atrial beats. METHODS AND RESULTS: The Atrial Pacing Preference (APP; Guidant, St Paul, MN, USA) algorithm allows the pacemaker to maintain a pacing rate slightly higher than the sinus rate. The preventive effects of APP on paroxysmal atrial fibrillation (AF) were studied in 51 patients (70+/-11 years). Nine patients did not complete the protocol. The pacemaker was programmed in random order to APP off and APP on at 3 different settings (ie, 8, 16 and 32 cycles) for 4 weeks each, using a cross-over design. Percentage atrial pacing was lower in APP off than at the other settings. Premature beat counts were greater in APP off than at the other settings. There was a significant difference in mode switch episode counts between APP off and the most effective setting (3,818+/-15,356 vs 596+/-1,719; p<0.01). CONCLUSIONS: The APP algorithm is a promising method for preventing atrial tachyarrhythmia in patients with an implanted pacemaker and AF. Optimizing the setting of the APP algorithm is an important issue in the prevention of AF.