Relationship between physical function at discharge and hospital meal intake in elderly patients with heart failure.

The relationship between low physical function (LPF) at discharge and food intake percentage (FIP) during hospitalization is unclear. We aimed to clarify the relationship between LPF at discharge and FIP and the change in nutritional status during hospitalization in elderly patients with heart failure (HF), and determine cutoff values for FIP and change in nutritional status during hospitalization. We included 431 consecutive patients aged ≥ 65 years who were hospitalized for HF and underwent cardiac rehabilitation (CR) from 2017 to 2019. Physical function at discharge was classified into two groups according to the Short Performance Physical Battery (SPPB): low physical function (LPF) (SPPB ≤ 9) and high physical function (HPF) (SPPB > 9). We compared background, clinical parameters, pre-hospital walking level, CR progress, nutritional factors during hospitalization including FIP of the main dish and side dish, and changes in nutritional status using the Geriatric Nutritional Risk Index (ΔGNRI) at admission and discharge. Multiple logistic regression analysis was also performed. The final analysis included 213 patients (age, 81.6 years) divided into the LPF (n = 136) and HPF groups (n = 77). The LPF group showed low FIP and a high ΔGNRI value. Multivariate analysis showed FIP main dish, ΔGNRI, worsening renal function, pre-hospital walking level, and days to start of walking to be factors influencing LPF at discharge. Respective cutoff values for FIP main dish and ΔGNRI predicting LPF at discharge were 82.2% and 4.24. FIP main dish during hospitalization and ΔGNRI were associated with LPF at discharge.

RS3PE syndrome developing during the course of probable toxic shock syndrome: a case report.

BACKGROUND: Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare syndrome characterized by "remitting," "seronegative" (namely rheumatoid factor-negative), and "symmetrical" synovitis with pitting edema on the dorsum of the hands and feet. Recently, there have been reports that serum vascular endothelial growth factor (VEGF) is elevated in this condition. CASE PRESENTATION: An 85-year-old man visited our department with a rash that had appeared 2 days earlier and a fever that had developed on the day of his visit. Based on clinical findings of fever, erythema exudativum multiforme, transitory hypotension, conjunctiva hyperemia, elevated creatine kinase, and desquamation, we suspected toxic shock syndrome (TSS). Therefore, we started treatment with vancomycin (1 g/day) and clindamycin (600 mg/day), after which his fever rapidly remitted. However, pitting edema on the dorsum of his hands and feet appeared on day 7, and the patient also had painful wrist and ankle joints. Additional tests were negative for rheumatoid factor, and anti-cyclic citrullinated protein antibodies were < 0.2 U/mL. Further, serum matrix metalloproteinase-3 (199.6 ng/mL; reference value ≤123.8 ng/mL) and serum VEGF (191 pg/mL; reference value ≤38.3 pg/mL) levels were elevated, and human leukocyte antigen-A2 was detected. The patient was thus diagnosed with RS3PE syndrome, for which he satisfied all four diagnostic criteria: 1) pitting edema in the limbs, 2) acute onset, 3) age ≥ 50 years, and 4) rheumatoid factor negativity. He was treated with oral prednisolone, resulting in the normalization of his serum VEGF level to 34.5 pg/mL 1 month after starting treatment. It is currently 1 year since disease onset, and although the patient has stopped taking prednisolone, there has been no recurrence of RS3PE syndrome. CONCLUSIONS: To the best of our knowledge, this is the first reported case of a patient developing RS3PE syndrome during the clinical course of TSS. We propose that the onset mechanism involved an increase in blood VEGF due to TSS, which induced RS3PE syndrome. As serum VEGF becomes elevated with both severe infections associated with shock and RS3PE syndrome, awareness that these conditions can occur concurrently is essential.

A case report of myocarditis combined with hepatitis caused by herpes simplex virus.

BACKGROUND: Viral myocarditis presents with various symptoms, including fatal arrhythmia and cardiogenic shock, and may develop into chronic myocarditis and dilated cardiomyopathy in some patients. We report a case of viral myocarditis and hepatitis caused by herpes simplex virus. CASE PRESENTATION: A 20-year-old woman was admitted to our hospital with fever, fatigue, and anorexia. The initial investigation showed elevated liver enzyme levels and elevated creatine phosphokinase, and computed tomography showed diffuse swelling and internal heterogeneous image in the liver. These findings were consistent with acute hepatitis; therefore, we performed a liver biopsy, which showed parenchymal necrosis and lymphocytic infiltration. The night that the liver biopsy was performed, blood pressure gradually decreased and revealed cardiogenic shock. Electrocardiography showed diffuse ST-segment elevation, and echocardiography showed a dilated, spherical ventricle with reduced systolic function and pericardial effusion. An endomyocardial biopsy revealed lymphocyte infiltration of the myocardium, confirming acute myocarditis. After a few days, tests for immunoglobin M and immunoglobin G antibodies against herpes simplex virus were positive. CONCLUSIONS: We presented a rare case of myocarditis combined with hepatitis that was caused by herpes simplex virus. Acute myocarditis can occur concurrently with hepatitis, pancreatitis, nephritis, and encephalitis; thus, determining the presence of other infectious lesions is necessary to provide appropriate treatment for the patient.

Lower on-treatment platelet reactivity during everolimus-eluting stent implantation contributes to the resolution of post-procedural intra-stent thrombus: serial OCT observation in the PRASFIT-Elective study.

Intra-stent thrombus (IS-Th) formed immediately after percutaneous coronary intervention (PCI) is associated with subsequent adverse coronary events. However, the impact of on-treatment platelet reactivity on IS-Th is unknown. PRASFIT-Elective is a multicenter study of PCI patients receiving prasugrel (20/3.75 mg, loading/maintenance dose) or clopidogrel (300/75 mg), with aspirin (100 mg). Among the 742 study patients, 111 were pre-specified for the OCT sub-study. Of these, 82 underwent OCT immediately after PCI to assess IS-Th and at an 8-month follow-up to evaluate the fate of the IS-Th. Lesions were considered resolved when IS-Th were detected after PCI but not on the follow-up or persistent when IS-Th were observed on both scans. The P2Y12 Reactive Unit (PRU) value was determined at the initial PCI and 4 and 48 weeks post-PCI. In 76 patients (86 lesions), we detected 230 IS-Th initially, and 196 IS-Th (85.2%) were resolved at the 8-month OCT. At PCI, but not 4 or 48 weeks after, the resolved IS-Th group had a lower PRU than the persistent IS-Th group (199 ± 101 vs. 266 ± 102, p = 0.008). Multivariate logistic regression analyses revealed that lower PRU at PCI and less calcified lesions were independent predictive factors for the resolution of IS-Th. Local lesion-related factors and lower on-treatment platelet reactivity at the time of PCI may contribute to the resolution of IS-Th after EES implantation, potentially improving clinical outcome.

Early Phase Arterial Reaction Following Drug-Eluting and Bare-Metal Stent Implantation in Patients With ST-Segment Elevation Myocardial Infarction.

The early phase arterial reaction after implantation of second-generation drug-eluting stents (2nd DES) and baremetal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear.The MECHANISM pilot study is a multi-center prospective registry that enrolled 24 STEMI patients (from 11 centers) who had undergone implantation of everolimus-eluting (n = 6), biolimus A9-eluting (n = 6) or zotarolimus-eluting stents (n = 6), or BMS (n = 6). Scheduled optical coherence tomography (OCT) was performed 2 weeks after implantation, and images were independently analyzed at a core laboratory in a blinded fashion. Intra-stent thrombus was quantitatively analyzed in terms of the maximal area and the percentage of cross-sections with thrombus (the numbers of cross-section with thrombus × 100 divided by total number of cross-sections within the stented segment). More than 90% of struts were already covered 2 weeks after the index procedure, regardless of the stent type. There were no differences in stent diameter, minimal lumen diameter, minimal lumen area, neointimal thickness, or the frequencies of malapposed and uncovered struts among the 4 groups. The quantity of intra-stent thrombus also did not differ among the 4 groups.The results of this pilot study suggest that the 2-week vascular responses seem to be similar among 2nd DES and BMS in STEMI patients. Considering the possible advantage of 2nd DES in the prevention of restenosis, 2nd DES are a feasible option for the treatment of patients with STEMI.

Neoatherosclerosis and mural thrombus detection after sirolimus-eluting stent implantation.

BACKGROUND: Although both optical coherence tomography (OCT) and angioscopy are robust tools for detecting intrastent thrombi and neoatherosclerosis in vivo, whether OCT findings are comparable with angioscopy findings remains unclear. METHODS AND RESULTS: 22 patients presenting with de novo lesions underwent 26 sirolimus-eluting stent (SES) implantations, with follow-up OCT and angioscopy at 10 months post-implantation for segmental assessment of the proximal, mid-, and distal SES segments (66 segments). The mean signal intensity index (signal intensity of the neointima/signal intensity of fibrous intimal hyperplasia) was quantified for angioscopically detected in-stent yellow and white segments. The detection rate for red thrombi was numerically higher with angioscopy than with OCT (17% vs. 9%; P=0.053). Angioscopically detected in-stent yellow segments were categorized into 3 OCT patterns: "high-attenuation tissue covering struts" (OCT-defined neoatherosclerosis), "high-attenuation tissue underneath struts," and "low-attenuation and low-intensity tissue covering struts"; further, macrophage-like appearance was most frequently observed with OCT-defined neoatherosclerosis (56%, 6.3%, and 0%, respectively, P<0.001). The mean signal intensity index of neoatherosclerosis was significantly lower than that of angioscopically detected in-stent white segments (0.929 vs. 0.997, P=0.004). CONCLUSIONS: Current OCT-based definitions for thrombus detection may underestimate the presence of subclinical red thrombi. Qualitative and quantitative OCT assessments of the neointima may enhance the detection of neoatherosclerosis over SES in vivo.

Vascular responses in patients with and without diabetes mellitus after everolimus-eluting stent implantation.

BACKGROUND: Previous reports have shown potential disadvantages of limus-derivative drugs for the stenting treatment of patients with diabetes mellitus (DM). METHODS AND RESULTS: We studied 159 coronary artery lesions (DM: n=72, non-DM: n=87) in 123 patients treated with everolimus-eluting stent (EES) and who underwent scheduled 9-month follow-up angiography with optical coherence tomography (OCT) regardless of symptoms. In addition to standard OCT variables, neointimal unevenness score (maximum/average neointimal thickness) and stent eccentricity index (minimum/maximum stent diameter) were calculated for each cross-section. To investigate a potential baseline difference between DM and non-DM lesions, pre- and post-interventional intravascular ultrasound (IVUS) images were also evaluated as an IVUS subgroup analysis. The average neointimal thickness and neointimal coverage did not differ between DM and non-DM patients. DM patients had, however, greater asymmetric stent expansion and variability of neointimal thickness than non-DM patients. There was a weak, but significant association between average stent eccentricity index and neointimal unevenness score. The IVUS substudy showed that the culprit plaque volume and plaque eccentricity in DM patients were significantly greater than in non-DM patients. CONCLUSIONS: Although EES provided a similar level of average neointimal thickness and coverage both in the presence and absence of DM, uneven neointimal suppression occurred in DM patients. A larger plaque volume of the culprit lesion may hamper symmetric stent expansion, possibly explaining the non-uniform neointimal suppression in DM patients.

Favorable vessel healing after nobori biolimus A9-eluting stent implantation-6- and 12-month follow-up by optical coherence tomography.

BACKGROUND: Nobori is a novel biolimus A9-eluting stent (BES) coated with a biodegradable polymer only on the abluminal side, which degrades over 6-9 months post-stent deployment. The course of vessel reaction after deployment at these time points remains unclear. METHODS AND RESULTS: We serially evaluated 28 BES implanted in de novo coronary lesions of 23 patients using optical coherence tomography (OCT) at 6 and 12 months post-stenting. Standard OCT variables, the percentage of stent with peri-strut low-intensity area (PLIA, a region around stent struts homogenously showing lesser intensity than the surrounding tissue, suggesting fibrin deposition or impaired neointima maturation) and that with in-stent thrombi were evaluated. There was a significant, but small increase in neointimal thickness (72 ± 23 to 82 ± 25 µm, P=0.006) from the 6- to the 12-month follow-up, without a significant decrease in minimum lumen area (P=0.30). The incidences of uncovered and malapposed struts were low at 6 months and reduced further at 12 months (3.96 ± 3.97% to 1.51 ± 1.63%, P=0.001, and 0.50 ± 1.84% to 0.06 ± 0.24%, P=0.20, respectively). The frequency of stent with PLIA decreased during the follow-up (57% to 32%, P=0.05) and that with in-stent thrombi also numerically decreased (7% to 0%, P=0.24). CONCLUSIONS: Neointimal hyperplasia was persistently suppressed following BES implantation up to 12 months. Simultaneously, favorable vessel healing was achieved at 6 months without a delaying adverse reaction for up to 12 months.

Minimally invasive coil embolization for significant left-to-right shunts due to giant coronary-to-pulmonary artery fistulas: a case report.

Background: Coronary-to-pulmonary artery fistula (CPF) is a rare disease, and its optimal treatment strategy remains controversial. Herein, we report a rare case of minimally invasive coil embolization of giant CPFs. Case summary: A 78-year-old man with a history of persistent atrial fibrillation and lumbar canal stenosis presented to our hospital with breathlessness. Cardiac computed tomography revealed giant CPFs inducing a significant left-to-right shunt (Qp/Qs 1/2.1) with a coronary artery aneurysm smaller than the size indicated for surgical treatment. To reduce the left-to-right shunt flow, coil embolization procedures for the fistulas were performed twice. Initially, the fistula arising from the right coronary artery was embolized using three Target® XXL (6 × 40 mm, 5 × 20 mm) and two Target® XL SOFT (4 × 12 mm) coils (Stryker Inc., Tokyo, Japan). One month later, the fistulas arising separately from the left coronary artery were embolized. After the procedures, the major shunt flow disappeared angiographically, and Qp/Qs significantly decreased to 1/1.2. Additionally, the fractional flow reserve of the left coronary artery increased from 0.79 to 0.93, and cardiopulmonary exercise testing showed an improvement in his exercise tolerance. Discussion: In similar cases, a surgical procedure with ligation of the CPFs combined with resection of a small aneurysm and coronary artery bypass grafting would normally have been considered the best approach. However, endovascular treatment targeting only the fistulas was a superior strategy considering the patient's age. The coil embolization technique effectively controlled the shunt flow of the CPFs. This technique is considerably less invasive than surgical therapy.

Potential benefit of final kissing balloon inflation after single stenting for the treatment of bifurcation lesions--insights from optical coherence tomography observations.

BACKGROUND: Treatment of coronary bifurcation lesions using a single stenting strategy is preferable over that using a 2-stent technique. The benefit of final kissing inflation (FKI), however, has not been established. METHODS AND RESULTS: Seventy-two patients (76 lesions) with true bifurcation lesions treated with a single drug-eluting stent with FKI (n=33 lesions) or without FKI (non-FKI, n=43 lesions) were enrolled in this study. Optical coherence tomography (OCT) was performed at 6-12 months after implantation. Based on the OCT findings, the percentage of jailing struts (number of jailing struts/total number of struts at the bifurcation lesion) was calculated. Percentage of uncovered struts and frequency of thrombus attachment were each evaluated at the proximal, bifurcation, and distal segments. Major adverse cardiac events (MACE) were also evaluated. The percentage of jailing struts was significantly lower in the FKI than in the non-FKI group (5.8±6.2% vs. 17.3±6.1%, P<0.01). Thrombus attachment was less frequent in the FKI group (24.2% vs. 46.5%, P=0.046), especially at side-branch orifices (3.0% vs. 27.9%, P<0.001). The percentage of uncovered struts was lower in the FKI than non-FKI group at the proximal, bifurcation, and distal segments. The incidence of MACE was not different in this small cohort. CONCLUSIONS: FKI might reduce the frequency of subclinical thrombus possibly by reducing the number of jailing struts.

Qualitative and quantitative assessment of stent restenosis by optical coherence tomography: comparison between drug-eluting and bare-metal stents.

BACKGROUND: We hypothesized that the tissue components of in-stent restenosis (ISR) might differ between drug-eluting stents (DES) and bare-metal stents (BMS) and that these differences could be distinguished by qualitative and quantitative optical coherence tomography (OCT) analyses. METHODS AND RESULTS: One-hundred and twenty-two initial ISR lesions (sirolimus-eluting stents: n=28; paclitaxel-eluting stents: n=51; BMS: n=43) were evaluated with OCT. Based on their OCT appearance, the lesions were classified as homogeneous, layered or heterogeneous. The optical properties of backscatter, attenuation and signal intensity of the neointimal tissue (NIT) were quantified. To evaluate the vascular response after balloon angioplasty (BA), the rate of reduction of the NIT area (NITA) was calculated (NITA before - after BA/NITA before BA at the minimum lumen cross-sectional area). Among the morphologic OCT patterns, the layered type was predominant with DES, whereas lesions were homogeneous with BMS (P<0.001). Backscatter and signal intensity were significantly higher with BMS (P<0.05 and P<0.001 respectively). The NITA reduction rate was significantly greater in the layered and heterogeneous groups than in the homogeneous group (P<0.01). CONCLUSIONS: The morphologic OCT patterns of the NIT in ISR differed significantly between DES and BMS, probably reflecting pathologic differences. Layered and heterogeneous tissues might respond better than homogeneous tissue to simple balloon dilatation, suggesting a possible direction for OCT-based ISR treatment strategies.

Right ventricular mural infective endocarditis after traumatic tricuspid valve regurgitation in a 40-year-old man: A case report.

As the clinical manifestations of traumatic tricuspid valve regurgitation vary according to the extent of tricuspid valve injury, this condition can often go unnoticed and be incidentally discovered. Here, we report the case of a 40-year-old man with patent foramen ovale, in which severe tricuspid regurgitation due to tricuspid valve prolapse was incidentally discovered following blunt chest trauma. Further examination revealed that the prolapse had also caused active right ventricular mural infective endocarditis. The patient had no relevant past medical history of chronic debilitating disease or immunosuppression. After evaluation by the cardiology team, emergent surgical tricuspid valvular repair was successfully performed. Learning objective: Tricuspid valve prolapses resulting from chest trauma may occasionally lead to severe tricuspid regurgitation. Furthermore, this may cause active right ventricular infective endocarditis. In the present case, Staphylococcus aureus was detected in blood cultures, which is usually rapidly progressive and often leads to devastating consequences. Early surgical approach should be considered in cases of infection in the left atrium via patent foramen ovale.

Pseudo dilated cardiomyopathy: Dilated cardiomyopathy-like changes due to a combination of stuck mechanical mitral valve and coronary microvascular dysfunction-An autopsy case.

Thrombus formation in the microvessels and endocardium was suggestive of endothelial cell damage, myocardial ischemia, and a decreased coronary flow reserve. Sustained pulmonary hypertension due to thrombosis worsened the biventricular dysfunction.

Acute myocarditis secondary to Campylobacter jejuni enteritis: A case report.

Acute myocarditis is a rare complication of Campylobacter jejuni enteritis. Herein, we report the case of a 20-year-old man who presented with chest pain that developed three days after the onset of enteritis. Electrocardiogram, echocardiogram, and cardiac enzyme levels suggested myocarditis. Cardiac magnetic resonance imaging revealed a late gadolinium enhancement in the inferior wall. Degeneration and necrosis of myocardial cells and lymphocyte-dominant inflammatory cell infiltration were found in the tissue obtained by endomyocardial biopsy. Acute myocarditis associated with C. jejuni enteritis was confirmed by these findings and C. jejuni detected in the stool culture. The symptoms of enteritis and myocarditis remitted 10 days after the onset. The left ventricular ejection fraction was improved from 40 % to 57 %.In previous cases, endomyocardial biopsy has not been performed because of mild myocarditis. The lack of pathological reports makes the mechanism of myocarditis associated with C. jejuni enteritis unknown. We report a case of myocarditis associated with C. jejuni enteritis, which was diagnosed using cardiac magnetic resonance imaging and endomyocardial biopsy. Learning objective: Acute myocarditis is a rare but important complication of Campylobacter jejuni enteritis. Cardiac magnetic resonance imaging is useful for diagnosis. Most cases of myocarditis associated with C. jejuni enteritis were mild and remitted without specific treatment. In the present case, endomyocardial biopsy was performed and CD4-positive lymphocytes were predominantly detected in the myocardial tissue.

Association between worsening renal function severity during hospitalization and low physical function at discharge: a retrospective cohort study of older patients with heart failure and chronic kidney disease from Japan.

BACKGROUND: The number of hospitalized older patients with chronic heart failure, chronic kidney disease, and worsening renal function is rising in Japan. This study aimed to clarify the impact of the severity of worsening renal function during hospitalization on low physical function at discharge of these patients. METHODS: We included 573 consecutive heart failure patients who underwent phase I cardiac rehabilitation. Worsening renal function severity was defined according to elevation during hospitalization of baseline serum creatinine on admission: non-worsening renal function, serum creatinine < 0.2 mg/dL; worsening renal function II/I, serum creatinine ≥ 0.2 to < 0.5 mg/dL; worsening renal function III, and serum creatinine ≥ 0.5 mL/dL. Physical function was measured with the Short Performance Physical Battery. We compared background factors, clinical parameters, pre-hospitalization walking levels, Functional Independence Measure score, and physical function in the three renal function groups. Multiple regression analysis was performed with the Short Performance Physical Battery at discharge as the dependent variable. RESULTS: The final analysis included 196 patients (mean age 82.7 years, male 51.5%) categorized into three groups based on worsening renal function: worsening renal function grade III group (n = 55), worsening renal function grade II/I group (n = 36), and non-worsening renal function group (n = 105). There is no significant difference in walking levels before hospitalization between the three groups, but physical function at discharge was significantly lower in the worsening renal function III group. Moreover, worsening renal function III was an independent factor for low physical function at discharge. CONCLUSION: Worsening of renal function during hospitalization in older patients with heart failure and chronic kidney disease was strongly associated with low physical function at discharge, even after adjusting for other potentially confounding factors, such as pre-hospitalization walking levels, walking start day, and Geriatric Nutrition Risk Index at discharge. Notably, worsening renal function of mild or moderate severity (grade II/I) did not show a significant association with low physical function.

Impact of stent platform of paclitaxel-eluting stents: assessment of neointimal distribution on optical coherence tomography.

BACKGROUND: The Taxus Express™ paclitaxel-eluting stent (Express-PES) and Taxus Liberté™ PES (Liberté-PES) have identical drugs, drug doses, and polymers, but different stent platforms. The Liberté-PES platform has thinner struts, specifically designed for more uniform drug elution. METHODS AND RESULTS: Fifty-four patients who underwent 6-month follow-up optical coherence tomography (OCT) after Express-PES (n=27) or Liberté-PES (n=27) implantation were enrolled. Longitudinal and circumferential uniformity of neointimal distribution was evaluated in 3-D by computing mean neointimal thickness (NIT) within 360 equally spaced radial sectors for every 1-mm cross-section. After stenting, intravascular ultrasound showed that Liberté-PES had a significantly smaller maximum angle between adjacent struts, with a tendency toward a lower incidence of % length of the segment with maximum angle >90° than Express-PES. Liberté-PES had a significantly thinner mean NIT than the Express-PES with comparable frequency of uncovered struts. Longitudinal and circumferential absolute variation of NIT expressed by standard deviation of NIT from each sector was significantly smaller for Liberté-PES than for Express-PES. Liberté-PES had a tendency toward a decreased incidence of thrombus and peri-strut low-intensity areas (findings suggestive of delayed arterial healing), compared to Express-PES. CONCLUSIONS: Stent design and thickness appeared to affect neointima suppression of PES. The stent platform of the Liberté-PES may offer greater and more homogeneous reduction of neointimal proliferation spatially across the full length of the PES.

Effect of cytochrome P450 2C19 polymorphism on target lesion outcome after drug-eluting stent implantation in japanese patients receiving clopidogrel.

BACKGROUND: Cytochrome P450 (CYP) 2C19 polymorphism is associated with reduced responsiveness to clopidogrel and poor clinical outcome after drug-eluting stent (DES) implantation, but its contribution to lesion outcome after DES implantation is unclear. METHODS AND RESULTS: The study included 160 Japanese patients who received clopidogrel and underwent DES implantation with follow-up angiography. Patients were divided into 3 groups by CYP2C19 polymorphism: extensive metabolizers (EM), intermediate metabolizers (IM), and poor metabolizers (PM). The incidence of major adverse cardiac events (MACE) and target lesion revascularization (TLR) were compared among the 3 groups. Optical coherence tomography (OCT) was performed for 120 patients to evaluate the incidence of intra-stent thrombi. Of the 160 patients, the proportion of EM, IM, and PM was 37.5%, 48.1%, and 14.4%, respectively. The incidence of TLR and MACE was more frequent in IM and PM than EM (TLR: 18.2% and 26.1% vs. 3.3%, P=0.008, MACE: 22.1% and 30.4% vs. 5.0%, P=0.005). Among the 120 patients who underwent follow-up OCT, intra-stent thrombi were more frequently detected in IM and PM than in EM (45.6% and 63.2% vs. 20.5%, P=0.005). The incidence of TLR was significantly higher in patients with than in those without intra-stent thrombi (27.7% vs. 6.8%, P=0.003). CONCLUSIONS: CYP2C19 loss-of-function polymorphism might be associated with the incidence of MACE and TLR in association with intra-stent thrombi.

A case of venous thromboembolism caused by protein C deficiency due to a novel gene mutation.

Hereditary protein C (PC) deficiency is a quantitative or qualitative abnormality of the coagulation regulator PC resulting in a decreased PC activity. It is caused by mutations in the PC gene (PROC) located on chromosome 2q13-q14. Although hereditary PC deficiency is an important risk factor for venous thromboembolism (VTE), it is often overlooked because of difficulties in genetic examination. The low prevalence of this disease has led to a lack of evidence for its treatment. We report the case of a 21-year-old male with VTE caused by hereditary PC deficiency due to a novel PROC gene mutation, c.566G>A, p.Arg 189 Gln. The patient was refractory to treatment with direct oral anticoagulants, but responded to catheter-directed thrombolysis. Further intrafamilial genetic survey revealed the presence of the same mutation in five of the six family members. Learning objectives: Venous thromboembolism (VTE) caused by hereditary protein C deficiency that is refractory to direct oral anticoagulants may respond to catheter-directed thrombolysis. Furthermore, the first VTE in young patients with a strong family history and female family members of childbearing age should be considered for genetic testing. In addition, genetic examination will help establish evidence for the treatment of such patients.

The role of EUS elastography-guided fine needle biopsy in the histological diagnosis of solid pancreatic lesions: a prospective exploratory study.

This study aimed to evaluate the feasibility and efficacy of Endoscopic ultrasound elastography-guided fine needle biopsy (EUS-EG-FNB) for the diagnosis of pancreatic mass lesions. EUS-EG images were classified into heterogeneous and homogeneous groups. For the heterogeneous group, EUS-FNB was separately performed in both hard areas and soft areas. Only samples obtained during the first two passes (hard/soft areas) were used to compare the diagnostic accuracy as well as the quality and quantity of the specimens. We investigated the association of EUS-EG findings using strain histogram analysis with the histological findings. Fifty-five patients were enrolled including 25 patients with heterogeneous group. The homogeneous group had significantly lower mean strain value (hard) lesions. The adequate sampling rates from hard and soft areas were 88 and 92%, respectively (P = 0.6374). Comparison of the diagnostic accuracy and the quality and quantity of the histological core between hard and soft areas showed no significant differences. In pancreatic adenocarcinoma cases, the proportion of fibrous stroma in the core tissue was significantly correlated with the elasticity of the region. (R2 = 0.1226: P = 0.0022) EUS-EG may reflect tissue composition in pancreatic tumors, however, EUS-EG did not affect either the quality and quantity of the tissues obtained.Clinical Trial Registry No: UMIN-000033073.

Impact of cytochrome P450 2C19*2 polymorphism on intra-stent thrombus after drug-eluting stent implantation in Japanese patients receiving clopidogrel.

BACKGROUND: The cytochrome P450 (CYP) 2C19*2 polymorphism is associated with reduced responsiveness to clopidogrel and poor clinical outcome after stent implantation. Despite the high frequency of this polymorphism in Japanese patients, its contribution to cardiac events and stent thrombi after drug-eluting stent (DES) implantation is not clear in this population. METHODS AND RESULTS: One hundred Japanese patients received clopidogrel and underwent follow-up optical coherence tomography (OCT) after DES implantation. The patients were divided into 2 groups: those with at least one CYP2C19*2 allele (*2 carriers) and non-carriers. The incidence of stent thrombosis and major adverse cardiac events (MACE; ie, death, myocardial infarction, and target vessel revascularization) was compared between the 2 groups. In addition, OCT was used to evaluate the incidence of intra-stent thrombus, defined as a mass protruding into the lumen with significant attenuation. Of the 100 patients, 42 were *2 carriers. No remarkable differences in the baseline characteristics were noted. Although MACE did not differ significantly between the 2 groups, a subclinical intra-stent thrombus was detected more frequently in *2 carriers than in non-carriers (52.3% vs. 15.5%, P=0.0002). Multivariate logistic regression analysis showed that the presence of the CYP2C19*2 polymorphism was the only independent predictive factor for intra-stent thrombus (P=0.00006). CONCLUSIONS: From these results it is suggested that CYP2C19*2 polymorphism is associated with subclinical thrombus formation among Japanese patients receiving clopidogrel. (Circ J 2011; 75: 99-105).