Severe Left Ventricular Failure Unmanageable by Impella 5.0.

Mechanical circulatory support can be beneficial for patients with cardiogenic shock. Of these, the Impella has recently become the first-line device due to its feasibility, minimal invasiveness, and efficacy. We had a 58-year-old male with acute myocardial infarction followed by cardiogenic shock. We initially placed the patient on intra-aortic balloon pumping, which was switched to Impella 2.5 and could stabilize him. Unfortunately, the Impella 2.5 device suddenly stopped on the fifth day, thus, we tried to manage him by inotropes. However, his condition gradually deteriorated, so we applied Impella 5.0. Although his systemic circulation could be maintained, severe pulmonary hypertension persisted on Impella 5.0. He developed flash pulmonary edema, thus, we emergently added venoarterial extracorporeal membrane oxygenation on Impella 5.0 (ECPELLA). Then, we removed Impella 5.0 and changed peripheral venoarterial extracorporeal membrane oxygenation to central venoarterial extracorporeal membrane oxygenation. In this central venoarterial extracorporeal membrane oxygenation, we inserted the cannulas in the pulmonary artery and the left ventricle in addition to the usual cannulas in the ascending aorta and the right atrium. We aimed to control pulmonary arterial blood flow for lung protection as well as left ventricular unloading by this modification. However, his cardiac function showed no signs of recovery, and his lung condition showed further exacerbation. He was complicated by fungal sepsis and finally died of multi-organ failure. Although the Impella is an option, it is crucial to evaluate patients' condition carefully and to escalate the device, if needed, without delay.

Dexmedetomidine for dyspnoea.

Dexmedetomidine is a selective α2-adrenoreceptor agonist with a broad range of effects, including easily controllable sedation, analgesia and anxiolysis. Because of these favorable features, it has replaced traditional sedatives, such as benzodiazepines, and is becoming the first-line sedative for the patients in intensive care units. Terminally ill patients often need sedatives for symptom management, especially for dyspnoea. However, the use of dexmedetomidine in a palliative care setting has rarely been recognised to date. We experienced a patient nearing the end of life due to uncontrollable pulmonary haemorrhage on ventilator, whose dyspnoea was successfully managed by dexmedetomidine in addition to continuous intravenous infusion of oxycodone.

Perforation of the right atrial appendage during implantation of a leadless pacemaker.

We report a case of perforation of the right atrial appendage during implantation of a leadless pacemaker in a 94 years old woman. We performed emergency surgery to repair the perforation site. To our konwledge, there are few reports of right atrial perforation during a leadless pacemaker indwelling.

Prevalence, overlap, and interrelationships of physical, cognitive, psychological, and social frailty among community-dwelling older people in Japan.

Background The aim of this study is to explore the prevalence and overlap of physical, cognitive, psychological, and social frailty and their negative-interrelationships. Methods We conducted a survey of people aged ≥75 years in the region with the oldest population in Japan. Frailty was divided into physical, cognitive, psychological, and social frailty, which were evaluated with the Japanese version of the Cardiovascular Health Study (J-CHS) criteria, J-CHS and the Japanese version of the Montreal Cognitive Assessment, the Geriatric Depression Scale-15 and the Lubben Social Network Scale, respectively. Results Of the 268 participants (aged 81.5 ± 4.5 years), 48.1% and 8.6% had physical prefrailty and frailty; 68.3%, 13.0%, and 5.2% had mild cognitive impairment, dementia, and cognitive frailty; 25.7% and 5.2% had depressive mood and depression as psychological frailty; and 7.8% had social frailty, respectively. Path analysis showed that social frailty was associated with psychological frailty. Psychological frailty was associated with physical frailty. Physical frailty was associated with cognitive frailty. Multiple logistic regression analysis showed that independent determinants of physical robustness were female sex, age, and psychological robustness (odds ratio (OR) = 2.166, 0.831, 3.625, respectively). Determinants of cognitive robustness were age and psychological robustness (OR = 0.837, 7.079). Determinants of psychological robustness were physical, cognitive, and social robustness (OR = 3.759, 6.829, 5.037), and the determinant of social robustness was psychological robustness (OR = 4.489), respectively. Conclusions We demonstrated the prevalence, overlap, and interrelationships of different types of frailty and clarified the factors that may help to reduce frailty.

Usefulness of hybrid veno-arterial extracorporeal membrane oxygenation for lung ischemia-reperfusion injury after biventricular assist device implantation.

We experienced a case of fulminant myocarditis complicated by severe lung ischemia-reperfusion injury after switching from veno-arterial extracorporeal membrane oxygenation to biventricular assist device. We controlled lung blood flow by hybrid veno-arterial extracorporeal membrane oxygenation, which was established by modifying the biventricular assist device circuit without resternotomy, blood delivery to the pulmonary artery and blood removal from the left ventricle in addition to central veno-arterial extracorporeal membrane oxygenation, and accelerated lung recovery. The patient's lung damage and cardiac function were restored, and she completely recovered and was discharged without any complications. Regulation of lung blood flow is important and effective for lung ischemia-reperfusion injury after biventricular assist device implantation.

Effectiveness of a far-infrared low-temperature sauna program on geriatric syndrome and frailty in community-dwelling older people.

AIM: Although it is known that geriatric syndrome is associated with the development of frailty, it is not known whether an amelioration of geriatric syndrome also improves shared risk factors and frailty. METHODS: In total, 67 community-dwelling older people (79.6 ± 6.5 years, 49 women) participated in this study (41 were classified as pre-frail and 26 as frail). We analyzed indices of physical frailty and cognitive depression, exercise tolerance and health-related quality of life as frailty related indices, and the participants completed a questionnaire regarding common geriatric symptoms (cold extremities, leg edema, breathlessness, urinary incontinence, chronic headache, chronic pain, a sense of numbness, anorexia, constipation, insomnia and skin trouble) using numeric ratings. Frailty was evaluated using the Japanese version of the Cardiovascular Health Study (J-CHS) criteria. The participants then underwent a far-infrared low-temperature sauna (FILTS) program twice a week for 3 months and the above parameters were reassessed. RESULTS: After the FILTS program, there were significant differences in usual walking speed, peak oxygen uptake, Geriatric Depression Scale-15, health-related quality of life and the severity of several geriatric symptoms. Of the 67 participants, 18 showed improvements in their J-CHS frailty score, 47 showed no change and two showed reductions. Linear regression analysis showed that the change in the numeric rating of the coldness of extremities (B = -0.105, P = 0.013) and the cumulative numeric rating for geriatric syndromes (B = 0.044, P < 0.001) were independent determinants of the change in the J-CHS score. CONCLUSIONS: A 3-month FILTS program ameliorates geriatric syndrome, the severity of frailty and frailty related indices in older Japanese people. Geriatr Gerontol Int 2020; 20: 892-898.

A case of HeartMate II implantation in non-dilated left ventricle.

Left ventricular assist device is an established therapeutic option for the patient with end-stage heart failure. Recently, durable continuous-flow devices have replaced earlier generation of pulsatile devices and their desirable features are accelerating the utilization of these devices. However, their powerful performance could sometimes induce unfavorable complications such as sucking, especially in not so dilated left ventricle. Special maneuvers such as cannula position and lower pump speed may be reasonable for patients with non-dilated left ventricular, however, those managements have not been established yet to date. Right ventricular failure is also another concern in these devices. We experienced a patient who got a HeartMate II in spade-shaped, non-dilated left ventricle concomitant with right ventricular dysfunction, and successfully managed her.

Prevalence of frailty, cognitive impairment, and sarcopenia in outpatients with cardiometabolic disease in a frailty clinic.

BACKGROUND: Although frailty and cognitive impairment are critical risk factors for disability and mortality in the general population of older inhabitants, the prevalence and incidence of these factors in individuals treated in the specialty outpatient clinics are unknown. METHODS: We recently established a frailty clinic for comprehensive assessments of conditions such as frailty, sarcopenia, and cognition, and planned 3-year prospective observational study to identify the risk factors for progression of these aging-related statuses. To date, we recruited 323 patients who revealed symptoms suggestive of frailty mainly from a specialty outpatient clinic of cardiology and diabetes. Frailty status was diagnosed by the modified Cardiovascular Health Study (mCHS) criteria and some other scales. Cognitive function was assessed by Mini-Mental State Examination (MMSE), Japanese version of the Montreal Cognitive Assessment (MoCA-J), and some other modalities. Sarcopenia was defined by the criteria of the Asian Working Group for Sarcopenia (AWGS). In this report, we outlined our frailty clinic and analyzed the background characteristics of the subjects. RESULTS: Most patients reported hypertension (78%), diabetes mellitus (57%), or dyslipidemia (63%), and cardiovascular disease and probable heart failure also had a higher prevalence. The prevalence of frailty diagnosed according to the mCHS criteria, cognitive impairment defined by MMSE (≤27) and MoCA-J (≤25), and of AWGS-defined sarcopenia were 24, 41, and 84, and 31%, respectively. The prevalence of frailty and cognitive impairment increased with aging, whereas the increase in sarcopenia prevalence plateaued after the age of 80 years. No significant differences were observed in the prevalence of frailty, cognitive impairment, and sarcopenia between the groups with and without diabetes mellitus, hypertension, or dyslipidemia with a few exceptions, presumably due to the high-risk subjects who had multiple cardiovascular comorbidities. A majority of the frail and sarcopenic patients revealed cognitive impairment, whereas the frequency of suspected dementia among these patients were both approximately 20%. CONCLUSIONS: We found a high prevalence of frailty, cognitive impairment, and sarcopenia in patients with cardiometabolic disease in our frailty clinic. Comprehensive assessment of the high-risk patients could be useful to identify the risk factors for progression of frailty and cognitive decline.

Peak exercise stroke volume effects on cognitive impairment in community-dwelling people with preserved ejection fraction.

AIMS: The association of vascular dysfunction and amyloid beta deposition attracted attentions for its relationship with cognitive decline. Previous studies show the correlation between the declined cardiac function and the cognitive impairment. In the present study, we analysed the association between cognitive functions and cardiac parameters in community-dwelling people with preserved ejection fraction without heart failure. METHODS AND RESULTS: Subjects were 108 Japanese community-dwelling middle-aged and older adults with preserved ejection fraction (25 men and 83 women; mean age 74.7 years). Cardiac functional parameters at rest were assessed with B-type natriuretic peptide and echocardiography. The cardiopulmonary exercise test was used to test these parameters during exercise. Cognitive function was assessed with the Japanese version of the Montreal Cognitive Assessment (MoCA-J). Other indices were assessed biochemically, physiologically, and physically. There were significant correlations between MoCA-J score and age (r = -0.388), peak oxygen uptake (VO2 , r = 0.201), peak VO2 /heart rate (HR, r = 0.243), peak VO2 /weight (r = 0.244), peak metabolic equivalents (r = 0.244), usual walking speed (r = -0.200), and the Timed Up and Go test (r = -0.230). Multiple linear regression analysis showed peak VO2 /HR was an independent determinant of MoCA-J score after adjusting for potential confounders (B = 0.424). After 6 months of exercise training with 64 subjects, we found that the per cent change of peak VO2 /HR was related to the per cent change of MoCA-J score (r = 0.296). CONCLUSIONS: These results suggested that peak VO2 /HR (an index of stroke volume at peak exercise) might be associated with cognitive impairment based on the vascular cascade hypothesis.

Japanese version of the Montreal Cognitive Assessment cut-off score to clarify improvement of mild cognitive impairment after exercise training in community-dwelling older adults.

AIM: Physical exercise improves cognitive function in people with mild cognitive impairment (MCI). However, information about whether the degree of MCI before exercise training affects improvement in cognitive function is lacking. Therefore, we aimed to investigate the cut-off value in a MCI screening tool that predicts reversal to normal cognitive function after exercise training in older adults with MCI. METHODS: Participants included 112 Japanese community-dwelling older adult outpatients (37 men, 75 women; mean age 76.3 years). We administered the Japanese version of the Montreal Cognitive Assessment (MoCA-J) before and after exercise training. MCI was defined as a MoCA-J score <26. All participants underwent exercise training 2 days per week for 6 months, according to American Heart Association guidelines. RESULTS: The prevalence of MCI was 65.2%. After exercise training, 46.6% of participants with MCI reversed to normal cognitive function. The MoCA-J cut-off score to predict cognitive function potentially reversible to normal was 23, with receiver operating characteristic analysis showing an area under the curve of 0.80, sensitivity of 79.4% and specificity of 69.2%. Multiple logistic regression analysis to predict non-MCI after exercise training showed that MoCA-J score ≥23 (OR 6.9, P < .001), female sex (OR 3.4, P = .04) and age (OR 0.9, P = .04) were independent determinants. CONCLUSIONS: The MoCA-J cut-off score of 23 might be useful to predict cognitive function that is potentially reversible to normal among community-dwelling Japanese older adults with MCI. Geriatr Gerontol Int 2018; 18: 833-838.

The Jarvik 2000 left ventricular assist device as a bridge to transplantation: Japanese Registry for Mechanically Assisted Circulatory Support.

BACKGROUND: The Jarvik 2000 ventricular assist device features a miniaturized intraventricular pump and an intermittent low-speed function that facilitates aortic valve opening. Despite its long history, little is known about the Jarvik device with regard to post-implantation outcomes. METHODS: Prospectively collected data from 13 participating hospitals were extracted from the Japanese Registry for Mechanically Assisted Circulatory Support database to analyze mortality, morbidity and de-novo aortic regurgitation. Data on 83 patients who underwent implantation of the Jarvik 2000 were reviewed. Median support duration was 191 (maximum 758) days. All recipients underwent implantation as a bridge to transplantation. RESULTS: Overall survival proportions at 1 and 2 years were 85.0% and 79.3%, respectively. Nine patients were in INTERMACS Level 1, and 28 patients were on mechanical circulatory support at the time of implantation. Causes of death included stroke, infection and device malfunction. Three patients had their device removed: 2 at the time of heart transplantation and 1 after recovery of the left ventricle. Common adverse events included major bleeding (27.7%), new infection (31.3%), stroke (20.5%) and device malfunction (20.5%). De-novo aortic regurgitation was observed in 17 patients, 6 of whom developed at least moderate regurgitation during follow-up. CONCLUSIONS: Mid-term survival after Jarvik 2000 implantation was satisfactory and comparable to that reported by other national and international registries (INTERMACS and IMACS) for continuous-flow LVADs. De novo aortic regurgitation occurred despite the intermittent low-speed effect of this device, with some recipients experiencing progressive worsening of aortic regurgitation within 2 years post-implantation.

Preliminary report on the cost effectiveness of ventricular assist devices.

The aim of the present study was to perform a cost-effectiveness analysis (CEA) of ventricular assist devices (VAD) implantation surgery in the Japanese medical reimbursement system. The study group consisted of thirty-seven patients who had undergone VAD implantation surgery for dilated cardiomyopathy (n = 25; 67.6 %) or hypertrophic cardiomyopathy (n = 4; 10.8 %), and others (n = 8; 21.6 %). Quality-adjusted life years (QALYs) were calculated using the utility score and years of life. Medical reimbursement bills were chosen as cost indices. The observation period was the 12-month period after surgery. Then, the incremental cost-effectiveness ratio was calculated according to the VAD type. In addition, the prognosis after 36 months was estimated on the basis of the results obtained using the Markov chain model. The mean preoperative INTERMACS profile score was 2.35 ± 0.77. Our results showed that the utility score, which indicates the effectiveness of VAD implantation surgery, improved by 0.279 ± 0.188 (ΔQALY, p < 0.05). The cost of VAD implantation surgery was 313,282 ± 25,275 (ΔUS$/year) on the basis of medical reimbursement bills associated with therapeutic interventions. The calculated result of CEA was 364,501 ± 190,599 (ΔUS$/QALY). The improvement in the utility score was greater for implantable versus extracorporeal VADs (0.233 ± 0.534 vs. 0.371 ± 0.238) and ICER was 303,104 (ΔUS$/ΔQALY). Furthermore, when we estimated CEA for 36 months, the expected baseline value was 102,712 (US$/QALY). Therefore, VAD implantation surgery was cost effective considering the disease specificities.