Detection of dynamic lung hyperinflation using cardiopulmonary exercise testing and respiratory function in patients with stable cardiac disease: a multicenter, cross-sectional study.

BACKGROUND: Many patients with heart disease potentially have comorbid chronic obstructive pulmonary disease (COPD); however, there are not enough opportunities for screening, and the qualitative differentiation of shortness of breath (SOB) has not been well established. We investigated the detection rate of SOB based on a visual and qualitative dynamic lung hyperinflation (DLH) detection index during cardiopulmonary exercise testing (CPET) and assessed potential differences in respiratory function between groups. METHODS: We recruited 534 patients with heart disease or patients who underwent simultaneous CPET and spirometry (369 males, 67.0 ± 12.9 years) to scrutinize physical functions. The difference between inspiratory and expiratory tidal volume was calculated (TV E-I) from the breath-by-breath data. Patients were grouped into convex (decreased TV E-I) and non-convex (unchanged or increased TV E-I) groups based on their TV E-I values after the start of exercise. RESULTS: Among the recruited patients, 129 (24.2%) were categorized in the convex group. There was no difference in clinical characteristics between the two groups. The Borg scale scores at the end of the CPET showed no difference. VE/VCO2 slope, its Y-intercept, and minimum VE/VCO2 showed no significant difference between the groups. In the convex group, FEV1.0/FVC was significantly lower compared to that in the non-convex group (69.4 ± 13.1 vs. 75.0 ± 9.0%). Moreover, significant correlations were observed between FEV1.0/FVC and Y-intercept (r=-0.343), as well as between the difference between minimum VE/VCO2 and VE/VCO2 slope (r=-0.478). CONCLUSIONS: The convex group showed decreased respiratory function, suggesting a potential airway obstruction during exercise. A combined assessment of the TV E-I and Y-intercept of the VE/VCO2 slope or the difference between the minimum VE/VCO2 and VE/VCO2 slopes could potentially detect COPD or airway obstruction.

Predictors of late outcomes after concomitant tricuspid valve repair with left-sided valve surgery.

BACKGROUND: Concomitant tricuspid valve (TV) repair is a safe and effective procedure to protect against late moderate or greater tricuspid regurgitation (TR) after left-sided valve surgery, but studies regarding its late outcomes and recurrent TR are limited. This study aimed to reveal the late outcomes and explore the predictors of mortality and recurrent TR among patients who underwent concomitant TV repair with left-sided valve surgery. METHODS AND RESULTS: This study included 645 patients (mean age, 69.7 years; 44% male) who underwent concomitant TV repair with left-sided valve surgery (mitral valve surgery in 594 cases, aortic valve surgery in 172 cases) from 2006-2020. Preoperative TR was grade 4, 3, and less than 2 in 85, 235, and 325 patients, respectively. The median follow-up period was 4.6 (IQR 1.7-7.8) years. The in-hospital or 30-day mortality was 1.7% (n = 11). Regarding long-term outcomes after TV repair, 90.3% and 80.8% achieved 5- and 10-year survival, respectively, while 96.1% and 88.8% achieved 5- and 10-year freedom from recurrent TR, respectively. The following were independent predictors of overall mortality on multivariate analysis in patients with preoperative TR grade ≥ 3: prior pacemaker implantation, preoperative renal dysfunction, diabetes mellitus and NYHA class ≥ 3. Also, suture annuloplasty and ring type of ring annuloplasty were not independent risk factors for recurrent TR, classified as grade ≥ 3. CONCLUSIONS: Concomitant TV repair with left-sided valve surgery had acceptable outcomes in terms of survival and TR durability. In patients with preoperative TR grade ≥ 3, preoperative patient status had negative impacts on prognosis.

Serum zinc concentration in patients with myocardial infarction: a retrospective study.

BACKGROUND: Zinc regulates the oxidative stress and inflammatory signaling cascade and affects the development and deterioration of cardiovascular disease. We investigated the prognosis of developing heart failure in patients with myocardial infarction. METHODS: Patients with myocardial infarction (n = 243) were divided using the median value of zinc concentration on admission into low (< 66 µg/dL at admission, n = 111) and high zinc group (≥ 66 µg/dL at admission, n = 132). During follow-up (mean ± SD: 734 ± 597 days; median 691 days), admission due to heart failure was observed in 12 patients: 10 and 2 cases in the low and high zinc groups, respectively. RESULTS: The risk of admission due to heart failure was significantly higher in the low zinc than in the high zinc group (P = 0.0043). Relative to the high zinc group, the hazard ratio for admission due to heart failure was 15.7 (95% confidence interval 1.11-221, P = 0.042) via adjusted Cox proportional hazards analysis. Even after propensity score matching, the risk of admission due to heart failure was significantly higher in the low zinc than in the high zinc group (P = 0.048). CONCLUSION: Low serum zinc concentration may be a risk factor for admission due to heart failure after myocardial infarction.

A case of syncope after exertion due to sigmoid septum evaluated by exercise stress echocardiography.

A sigmoid septum is associated with sharp angulation and aging of the aortic root; however, it does not affect the pressure gradient in the left ventricular outflow tract and is generally asymptomatic. This report describes a 73-year-old woman who presented with syncope after exertion. Echocardiography revealed that the cause was left ventricular outflow tract stenosis associated with a sigmoid septum; her symptoms improved with beta-blocker therapy. Exercise stress echocardiography was performed to determine treatment efficacy. Sigmoid septum causes syncope on exertion; however, drug therapy is effective. Exercise stress echocardiography is effective in determining treatment efficacy. If syncope is present, a sigmoid septum should be considered as a cause. Learning objectives: 1.A sigmoid septum is part of or resembles hypertrophic cardiomyopathy, resulting in left ventricular outflow tract (LVOT) stenosis that is exacerbated by exertion and may cause syncope.2.A sigmoid septum is a differential diagnosis for the cause of syncope and is diagnosed using cardiac echocardiography.3.LVOT stenosis due to a sigmoid septum can be improved with drug therapy such as beta-blockers.4.The effects of beta-blocker therapy can be determined by exercise stress echocardiography.

Delayed traumatic aortic valve perforation after blunt chest trauma.

BACKGROUND: Aortic valve perforation is a rare complication of blunt chest trauma. We report a case of delayed aortic insufficiency presenting several months after trauma. CASE PRESENTATION: A 17-year-old male presented to the emergency department with traumatic brain injuries and blunt chest trauma, but no evidence of cardiac injuries. Three months later, he developed acute heart failure due to severe aortic valve regurgitation with left ventricular dysfunction. A sizable tear in the right coronary cusp caused aortic insufficiency. He was treated successfully by surgical replacement with an aortic bioprosthesis. CONCLUSION: We reported a successful surgical case of valve replacement for delayed aortic valve perforation. Delayed valve perforation should be kept in mind after blunt chest trauma.

Effect of constipation on readmission for heart failure in patients with acute heart failure.

AIMS: Constipation is a common gastrointestinal disorder that is associated with a high cardiovascular event rate in the general population. Although constipation is common in patients with cardiovascular diseases, only a few studies have examined the relationship between constipation and the prognosis of patients with heart failure. This study aimed to evaluate the effects of constipation on the prognosis of patients with acute heart failure. METHODS AND RESULTS: We investigated 397 patients admitted to our hospital from December 2020 to December 2022 with acute heart failure (mean age, 81 ± 13 years; 54% men). Patients with constipation were defined as those either taking laxatives regularly or diagnosed with constipation according to the International Statistical Classification of Diseases and Related Health Problems. During the follow-up periods (median, 173 days), 35 patients died, and 74 experienced readmission due to heart failure. Kaplan-Meier analysis before and after propensity score matching using 14 variables revealed that the risk of readmission due to heart failure was significantly higher in patients with constipation than in those without (before: log-rank P = 0.014, after: log-rank P = 0.0027). The adjusted Cox proportional hazards analysis revealed that the hazard ratio for readmission due to heart failure was 2.61 (95% confidence interval, 1.38-4.94, P = 0.0032). The risk of all-cause death was not significantly different between the two groups (hazard ratio, 1.76; 95% confidence interval, 0.61-5.06; P = 0.30). CONCLUSIONS: Constipation status was strongly associated with a higher risk of readmission for heart failure in patients with acute heart failure.

Short- and Midterm outcomes of modified robotic tricuspid annuloplasty for secondary tricuspid regurgitation.

BACKGROUND: Despite the growing popularity of robotically assisted mitral repair, robotically assisted tricuspid repair has not been widely adopted. We assessed the safety and feasibility of robotic tricuspid annuloplasty with continuous sutures for tricuspid regurgitation (TR). METHODS AND RESULTS: We studied consecutive 68 patients (median age, 74 years) with secondary TR who underwent tricuspid annuloplasty using continuous sutures with (n = 61) and without mitral valve repair (n = 7) from 2018 to 2021. Robotic tricuspid annuloplasty consists of continuous sutures with flexible prosthetic band to the tricuspid annulus using two V-Loc barbed sutures (Medtronic Inc., Minneapolis, MN). Concomitant maze procedure was performed in 45 (66%) patients. Robotic tricuspid annuloplasty with continuous sutures was successfully performed. There was no in-hospital or 30-day mortality; 65 patients (96%) did not experience major surgery-related complications. Preoperatively, the TR grade was mild in 20 (29%) patients and mildly higher in 48 (71%). Postoperatively, the TR severity significantly improved, with TR grade mildly higher in 9% at hospital discharge and 7% at 1-year follow-up (p < 0.001). The 1-year and 2-year freedom rates from heart failure were 98% and 95%, respectively. CONCLUSIONS: Robotic tricuspid annuloplasty with continuous sutures is safe and feasible alone or concomitant with mitral valve repair. It offered sustained improvement in TR severity and might prevent heart failure readmission.

The concept of detection of dynamic lung hyperinflation using cardiopulmonary exercise testing.

Dynamic lung hyperinflation (DLH) caused by air trapping, which increases residual air volume, is a common cause of shortness of breath on exertion in chronic obstructive pulmonary disease (COPD). DLH is commonly evaluated by measuring the decrease in maximal inspiratory volume during exercise, or using the hyperventilation method. However, only few facilities perform these methods, and testing opportunities are limited. Therefore, we investigated the possibility of visually and qualitatively detecting DLH using data from a cardiopulmonary exercise test (CPET). Four men who underwent symptom-limiting CPET were included in this study, including a male patient in his 60s with confirmed COPD, a 50s male long-term smoker, and 2 healthy men in their 20s and 70s, respectively. We calculated the difference between the inspiratory tidal volume (TV I) and expiratory tidal volume (TV E) per breath (TV E-I) from the breath-by-breath data of each CPET and plotted it against the time axis. No decrease in TV E-I was observed in either of the healthy men. However, in the patient with COPD and long-term smoker, TV E-I began to decrease immediately after the initiation of exercise. These results indicate that DLH can be visually detected using CPET data. However, this study was a validation of a limited number of cases, and a comparison with existing evaluation methods and verification of disease specificity are required.

Thoracic endovascular aortic repair with collateral vessels from the femoral artery to Adamkiewicz's artery.

Identification of the Adamkiewicz's artery (AKA) prior to the operation is one of the spinal cord ischaemia preventive measures. A 75-year-old man presented with the rapid expansion of thoracic aortic aneurysm. Collateral vessels from the right common femoral artery to the AKA were observed on preoperative computed tomography angiography. The stent graft was successfully deployed through the contralateral side via a pararectal laparotomy to avoid collateral vessel injury supplying the AKA. This case highlights the significance of preoperative identification of collateral vessels to the AKA.

Eicosapentaenoic Acid Preserves Mitochondrial Quality and Attenuates Cardiac Remodeling After Myocardial Infarction in Rats.

Eicosapentaenoic acid (EPA) reduces the risk of ischemic heart diseases and is a component of mitochondria. We herein investigated whether dietary EPA mediated mitochondrial fatty acid compositions, dynamics, and functions, resulting in the attenuation of cardiac remodeling after myocardial infarction (MI). The coronary artery of male rats was ligated to induce MI, and they were then treated with or without EPA (1000 mg/kg/day) for 12 weeks. The EPA treatment improved left ventricular systolic function and increased the mitochondrial content of EPA in the non-infarct region 12 weeks after MI. The content of ATP and mitochondrial complex II, III, and IV activities decreased after MI but were maintained by the EPA treatment in association with the preservation of optic atrophy 1, a mitochondrial fusion protein. The present results suggest that dietary EPA increased the mitochondrial content of EPA and preserved the expression of mitochondrial fusion proteins and energy metabolism, which attenuated left ventricular remodeling after MI.

Endovascular and Endoscopic Treatment for Primary Aortoduodenal Fistula: A Case Report.

Primary aortoduodenal fistula (ADF) is a relatively rare and morbid diagnosis. A 91-year-old man who developed hematemesis and melena was transferred from a community hospital with the diagnosis of a ruptured abdominal aortic aneurysm (AAA). Computed tomography revealed an irregular-shaped AAA with cavities enhanced near the duodenum, with suspected ADF. The patient was initially treated with emergency endovascular aneurysm repair. Duodenoscopy showed defects of the mucosa. ADF was diagnosed, and fistulas were closed with endoscopic clipping. This case highlights the success of ADF endovascular repair.

Type A aortic dissection with left coronary malperfusion.

Left coronary artery malperfusion is a fatal complication of acute type A aortic dissection. However, effective treatment strategies have not yet been established. Herein, we report two cases of left coronary artery malperfusion successfully treated with different preoperative catheter interventions, followed by a central aortic repair. Preoperative coronary intervention ensuring the blood flow to the left coronary artery might be essential if a coronary angiogram was performed prior to the diagnosis and treatment.

Higher Recurrence Rate of Acute Coronary Syndrome in Patients with Multiple-Time Myocardial Infarction.

The recurrence rate of acute coronary syndrome (ACS) in patients after first-time myocardial infarction (MI) is over ten times higher than in the general population. However, it is unclear whether patients with multiple-time MI have an even higher recurrence rate of MI. This study aimed to compare the recurrence rate in patients with multiple-time MI with the rate in patients after first-time MI. We retrospectively studied 794 consecutive MI patients who were discharged. Recurrent ACS was investigated in patients with previous MI (n = 46) and without previous MI (n = 748). During the follow-up periods (mean ± SD: 757 ± 733 days), recurrent ACS occurred in 47 cases without previous MI and in 7 cases with previous MI. Kaplan-Meier analysis revealed that the risk of recurrent ACS was significantly higher in patients with previous MI than in patients without previous MI. ACS recurrence rates one year from the onset were 4.2% in patients without previous MI and 11.9% in patients with previous MI. Landmark analysis revealed that the higher recurrence rate in patients with previous MI was as high as 14.1% from 1 year after the onset to 2 years. In conclusion, the risk of recurrent ACS may be significantly higher in patients with multiple-time MI than in patients after first-time MI.

Cardiovascular reactions for whole-body thermal therapy with a hot pack and Waon therapy.

Background: Waon therapy (WT) is the predominant thermal therapy for chronic heart failure in Japan, involving use of a far-infrared dry sauna. As sauna therapy requires certain equipment not readily available in hospitals, we tested the use of whole-body hot pack thermal therapy (HPTT). We compared the magnitude of skin vasodilation post-HPTT with that post-WT.Methods: We recruited 19 healthy men (age [mean ± S.D.]: 26.8 ± 4.6 years) and employed a simple randomized crossover design. The HPTT required subjects to remain in a supine position on a bed for at least 10 min. Hot packs were then applied on the back, lower abdomen, and popliteal regions for 15 min (warming phase). Participants continued bed rest for 30 min (heat-retention phase) after removal of the hot pack. WT was performed as previously described. Blood pressure (BP), heart rate (HR), tympanic temperature (TT), and peak and average flow velocity of the right radial artery (PFV and AFV, respectively) and right brachial artery (BA) diameter were measured during HPTT and WT.Results: HR, TT, PFV, and AFV persistently and significantly increased during warming and heat-retention phases of HPTT. In WT, HR and TT significantly increased during warming but decreased and plateaued during heat-retention. BP did not change significantly after either therapy; however, BA was dilated equally in both (HPTT: 3.70 ± 0.57 ⇒ 4.05 ± 0.59 mm, p = .001; WT: 3.63 ± 0.63 ⇒ 3.93 ± 0.61 mm, p < .001).Conclusion: HPTT may be equivalent to WT with respect to vasodilation response of the skin.

Percutaneous transradial artery approach for femoro- popliteal artery intervention in the current era in Japan.

The percutaneous transradial artery approach for coronary angiography and intervention has been recognized as a safe and effective method, however, it is limited for endovascular therapy (EVT) for femoro-popliteal artery because of lack of devices with longer shaft. Herein, we report two EVT cases for superficial femoral artery disease treated with a long shaft balloon through the radial artery. Although femoro-popliteal artery intervention with this approach has several limits for available devices and technical issues, it is effective for particular patients who are impossible in EVT with femoral artery approach.

Comparison of the measured pre-ejection periods and left ventricular ejection times between echocardiography and impedance cardiography for optimizing cardiac resynchronization therapy.

BACKGROUND: The pre-ejection period (PEP) and left ventricular ejection time (LVET) are easily measured by impedance cardiography (ICG). We hypothesized that the PEP/LVET measured by ICG would correlate with that measured by echocardiography, and that PEP/LVET measured by ICG would be useful for cardiac resynchronization therapy (CRT) optimization. METHODS: Newly CRT implanted patients were optimized by echocardiography. The PEP/LVET was measured by echocardiography and ICG in two different settings: optimized setting and right ventricle (RV)-only pacing. RESULTS: The PEP/LVET was significantly decreased in the optimized setting compared with that in RV-only pacing (0.62±0.13 vs 0.75±0.16, p<0.05). The PEP/LVET values calculated by ICG and echocardiography were positively correlated (r=0.553, p=0.003). CONCLUSION: ICG was useful for the optimization of CRT.

Effect of glycemic state on postprandial hyperlipidemia and hyperinsulinemia in patients with coronary artery disease.

Both postprandial hyperlipidemia and hyperinsulinemia have been thought to play an important role in the development of atherosclerosis, and to be a potent risk factor for cardiovascular event. To examine effects of glycemic state on postprandial hyperlipidemia and hyperinsulinemia in patients with coronary artery disease (CAD), a total of 112 consecutive male pati ents with angiographically confirmed CAD were loaded with a high-fat and high-glucose test meal. CAD patients were divided into three groups as "non-diabetic", "prediabetic", and "diabetic" CAD groups. The serum triglyceride (TG) and remnant-like particle cholesterol (RLP-C) levels at the 6th hour in diabetic CAD group showed significantly higher than non-diabetic CAD group, and the incremental area under the curves (iAUCs) of these levels in diabetic CAD group were significantly greater than non-diabetic CAD group (TG, P = 0.0194; RLP-C, P = 0.0219). There were no significant differences in the iAUCs of TG or RLP-C between prediabetic and non-diabetic CAD group. The AUCs of plasma insulin levels or insulin resistance index (IRI): (AUCs of insulin) × (AUCs of glucose) as the insulin resistance marker were greater in diabetic CAD group than non-diabetic CAD group (insulin, P = 0.0373; IRI, P = 0.0228). The AUCs of serum TG or RLP-C levels showed a correlation with the AUCs of plasma insulin (AUC-TG, r = 0.5437, P < 0.0001; AUC-RLP-C, r = 0.6847, P < 0.0001), and they correlated well with the insulin resistance index (AUC-TG, r = 0.7724, P < 0.0001; AUC-RLP-C, r = 0.7645, P < 0.0001). We found that the insulin resistance showed a close relationship with postprandial hyperlipidemia in CAD patients. Diabetic, but not prediabetic state, may be a risk for postprandial impaired lipid metabolism in CAD patients.

Different postprandial lipid metabolism and insulin resistance between non-diabetic patients with and without coronary artery disease.

BACKGROUND: Postprandial hyperlipidemia and hyperinsulinemia have been thought to play an important role in the development of atherosclerosis. Diabetes mellitus (DM) has an impact on lipid metabolism, however, little is known about the relationship between the postprandial lipid and glucose metabolism in normoglycemic patients with coronary artery disease (CAD). METHODS: To compare the postprandial lipid and glucose metabolism in normoglycemic patients with and without CAD, a total of 36 normoglycemic patients: 19 patients with stable CAD (CAD group, age 60.2±11.3 years) and 17 patients without CAD (Non-CAD group, age 60.4±9.6 years) were loaded with a high-fat and high-glucose test meal, and the changes in serum level of the lipid and glucose parameters were monitored before and 0, 2, 4, and 6h later. RESULTS: In the Non-CAD group, postprandial serum levels of triglycerides (TG) and remnant-like particle cholesterol increased significantly and reached peak levels at the 4th hour and decreased significantly at the 6th hour of observation, whereas those levels in CAD group kept rising during 6h of observation. Although there was no significant difference in the area under the curves (AUCs) for the postprandial plasma glucose levels between CAD and Non-CAD group, the AUCs for the postprandial plasma insulin and C-peptide levels were significantly higher in the CAD group than in the Non-CAD group. The AUCs for postprandial TG levels showed good correlation with those for postprandial plasma insulin and C-peptide levels (insulin: r=0.455, p<0.005; C-peptide: r=0.462, p<0.05). CONCLUSIONS: These findings suggest that postprandial hyperlipidemia and hyperinsulinemia may have a close relationship in CAD patients without DM and might play an important role in the development of atherosclerosis even before the onset of diabetes.

Opposing roles of nitric oxide and rho-kinase in lipid metabolism in mice.

Dyslipidemia is a life-style disorder and is one of the important risk factors of cardiovascular diseases. Nitric oxide (NO) exerts beneficial effects on lipid metabolism through activation of hepatic sterol regulatory element-binding protein (SREBP)-2, a transcriptional factor for cholesterol metabolism and expression of LDL receptor, while Rho-kinase, an effecter protein of small G protein, RhoA, contributes to the pathogenesis of metabolic syndrome through suppressing the whole body energy consumption. However, the crosstalk between NO and Rho-kinase in regulation of lipid metabolism remains to be elucidated. In the present study, we used male wild-type (WT) mice and mice lacking three isoforms of NO synthase (NOSs(-/-)). WT mice were fed either normal diet (ND) or high-fat diet (HFD), while NOSs(-/-) mice were fed ND with or without a selective Rho-kinase inhibitor, fasudil (100 mg/kg/day), for 6 weeks. At 6 weeks, plasma NOx concentration was significantly decreased and Rho-kinase activity and lipid levels were significantly elevated in HFD-fed WT mice and NOSs(-/-) mice compared with ND-fed WT mice. In the liver, SREBP-2 activity was reduced in NOSs(-/-) mice. Fasudil ameliorated lipid levels in HFD-fed WT mice and NOSs(-/-) mice without affecting SREBP-2 activity or LDL receptor expression, whereas it significantly enhanced phosphorylation of AMP-activated kinase (AMPK) in the liver and skeletal muscle. Importantly, the beneficial metabolic effects of fasudil were absent in HFD-fed AMPK(-/-) mice. These results provide the first evidence that NO and Rho-kinase play opposing roles for the lipid metabolism, suggesting that Rho-kinase inhibitors could be novel therapeutic agents of dyslipidemia.

Contrast stainings outside the stents of the superficial femoral artery after polymer-free drug-eluting peripheral stents implantation.

A 65-year-old man with occlusion of the left superficial femoral artery (SFA) underwent the endovascular therapy (EVT). A successful EVT was performed with three paclitaxel-eluting peripheral stents (Zilver PTX®) implanted in the left SFA. Angiography 1 year later showed an exudation of contrast outside the stent struts, and intravascular ultrasound, and optical coherence tomography also showed incomplete stent apposition with remarkable positive vascular remodeling. Zilver PTX® stent is a polymer-free stent and it is unclear that the reason why the patient treated with Zilver PTX® stents in the SFA lesions caused the contrast stainings outside the stents. However, we need more careful long-term follow-up of this patient for late thrombosis.