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

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

Triggers of Ventricular Fibrillation in Patients With Inferolateral J-Wave Syndrome.

BACKGROUND: There are few data on ventricular fibrillation (VF) initiation in patients with inferolateral J waves. OBJECTIVES: This multicenter study investigated the characteristics of triggers initiating spontaneous VF in inferolateral J-wave syndrome. METHODS: A total of 31 patients (age 37 ± 14 years, 24 male) with spontaneous VF episodes associated with inferolateral J waves were evaluated to determine the origin and characteristics of triggers. The J-wave pattern was recorded in inferior leads in 11 patients, lateral leads in 3, and inferolateral leads in 17. RESULTS: The VF triggers (n = 37) exhibited varying QRS durations (176 ± 21 milliseconds, range 119-219 milliseconds) and coupling intervals (339 ± 46 milliseconds, range 250-508 milliseconds) with a right (70%) or left (30%) bundle branch block (BBB) pattern. Trigger patterns were associated with J-wave location: left BBB triggers with inferior J waves and right BBB triggers with lateral J waves. Electrophysiologic study was performed for 22 VF triggers in 19 patients. They originated from the left or right Purkinje system in 6 and from the ventricular myocardium in 10 and were undetermined in 6. Purkinje vs myocardial triggers showed distinct electrocardiographic characteristics in coupling interval and QRS-complex duration and morphology. Abnormal epicardial substrate associated with fragmented electrograms was identified in 9 patients, with triggers originating from the same region in 7 patients. Catheter ablation resulted in VF suppression in 15 patients (79%). CONCLUSIONS: VF initiation in inferolateral J-wave syndrome is associated with significant individual heterogeneity in trigger characteristics. Myocardial triggers have electrocardiographic features distinct from Purkinje triggers, and their origin often colocalizes with an abnormal epicardial substrate.

Short-Term Treatment with Empagliflozin Resulted in Dehydration and Cardiac Arrest in an Elderly Patient with Specific Complications: A Case Report and Literature Review.

Empagliflozin is a sodium-glucose cotransporter-2 inhibitor widely used in the treatment of diabetes mellitus and heart failure. Our case study involved a 68-year-old patient who was admitted to the hospital because of a cerebral infarction. The patient was simultaneously diagnosed with diabetes mellitus and heart failure, for which empagliflozin was initiated. However, food and fluid intake were reduced due to poor appetite. In addition to the side effects of empagliflozin, the patient developed severe dehydration and cardiac arrest. Careful assessment of dehydration and preventive water intake is recommended in elderly patients and those with neurological deficits, especially when receiving empagliflozin.

Long distance of spontaneous coronary artery dissection involving LMT in a middle-aged man - Complete rapid healing and clinical usefulness of CABG as a temporizing strategy.

Spontaneous coronary artery dissection (SCAD) usually occurs in women, which can result in significant morbidities. A 38 year-old obese man who is currently smoking was referred to our hospital with chest pain. His electrocardiography and echocardiography suggested myocardial infarction in proximal region of left coronary artery. Emergent coronary angiography revealed 99% stenosis at mid portion of LAD and diffuse 50% stenosis from LMT to LAD. Intravascular ultrasound identified intramural hematoma severely compressing the true lumen which extended from mid LAD to LMT suggesting SCAD. After failed fenestration of the false lumen with balloon angioplasty, emergent coronary artery bypass graft using right internal thoracic artery and saphenous vein graft was performed. Two weeks after the surgery, follow-up CAG found completely healed native coronary artery which resulted in occlusion of RITA-LAD graft. This case raises two clinical important issues. First, SCAD can be seen in middle-aged men who are likely to have atherosclerosis. Secondly, CABG is useful as temporizing strategy for unstable SCAD involving LMT. The rapid healing and temporal lifesaving CABG contributed to avoidance of lifelong antiplatelet therapy. Although SCAD is relatively uncommon manifestation of acute coronary syndrome, optimal diagnosis and treatment for each patient need to be considered. .

A case of cardiac sarcoidosis mimicking cardiac amyloidosis on cardiovascular magnetic resonance.

A 52-year-old male visited our hospital with abnormal electrocardiogram and exertional fatigue. The electrocardiogram showed first-degree atrioventricular block, complete right bundle branch block, and inverted T waves in Leads II, III, aVF, V3, and V4. Echocardiography showed biventricular wall thickening involving granular sparkling of the interventricular septum. Late gadolinium enhancement on cardiovascular magnetic resonance (CMR) was found at the circumferential right ventricular wall and patchy regions of the left ventricle. Although these findings strongly suggested cardiac amyloidosis, he was finally diagnosed with systemic sarcoidosis due to the following. First, endomyocardial biopsy revealed non-caseating epithelioid granuloma with giant cells. Second, 18 F-fluorodeoxyglucose positron emission tomography showed uptake in bilateral hilar lymph nodes, para-aortic lymph nodes, and the biventricular wall of the heart. Although echocardiography and CMR are very useful tools for diagnosis of cardiomyopathies, their specificity and accuracy need to be considered.