Relative increase in production ratio of small dense low-density lipoprotein in acute coronary syndrome with high coronary plaque burden: an ex-vivo analysis.

The absolute value of small dense low-density lipoprotein (sd-LDL) including small LDL (s-LDL) and very small LDL (vs-LDL) has been shown to be associated with increased incidence of atherosclerosis. However, the impact of short-timeframe increases in sd-LDL on arteriosclerosis has not yet been elucidated. Therefore, we investigated the clinical roles of ex-vivo induced sd-LDL in acute coronary syndrome (ACS) using a novel method. This is a prospective, single-blind, and observational study that screened patients who underwent coronary angiography (CAG) for the treatment of ACS or investigation of heart-failure etiology between June 2020 and April 2022 (n = 247). After excluding patients with known diabetes mellitus and advanced renal disease, the patients were further divided into the ACS (n = 34) and control (non-obstructive coronary artery, n = 34) groups. The proportion of sd-LDL (s-LDL + vs-LDL) in total lipoproteins was observed before and after 2-h incubation at 37 ℃ (to approximate physiologic conditions) using 3% polyacrylamide gel electrophoresis. The coronary plaque burden was quantified upon CAG in the ACS group. There were no significant differences between the ACS and control groups in terms of clinical coronary risk factors. The baseline of large, medium, small, and very small LDL were comparable between the two groups. Following a 2-h incubation period, significant increases were observed in the ratios of s-LDL and vs-LDL in both the ACS and control groups (ACS, p = 0.01*; control, p = 0.01*). Notably, the magnitude of increase in sd-LDL was more pronounced in the ACS group compared to the control group, with s-LDL showing a significant difference (p = 0.03*) and vs-LDL showing a tread toward significance (p = 0.08). In addition, in both groups, there was a decrease in IDL and L-LDL, while M-LDL remained unchanged. The plaque burden index and rate of short-timeframe changes in both s-LDL (p = 0.01*) and vs-LDL (p = 0.04*) before and after incubation were significantly correlated in the ACS group. The enhanced production rate of sd-LDL induced under short-term physiologic culture in an ex-vivo model was greater in patients with ACS than in the control group. The increase in sd-LDL is positively correlated with coronary plaque burden. Short-timeframe changes in sd-LDL may serve as markers for the severity of coronary artery disease.

Predictors of New-Onset Atrial Tachyarrhythmias After Transcatheter Atrial Septal Defect Closure in Adults.

BACKGROUND: New-onset atrial tachyarrhythmia (ATA) often develops after atrial septal defect (ASD) closure. Its development raises some potential concerns such as stroke and bleeding complications caused by anticoagulant therapy and limited access to the left atrium for catheter ablation. Although it is essential to identify the risk factors of new-onset ATA, few studies have examined these factors. This study investigated unknown risk factors for the development of new-onset ATA after transcatheter ASD closure in patients without a history of ATA. METHODS: A total of 238 patients without a history of ATA, aged ≥18 years and who underwent transcatheter ASD closure at the current hospital were reviewed. Patient characteristics were compared between the groups with and without new-onset ATA. The factors associated with new-onset ATA were examined using univariate and multivariable analyses. RESULTS: Thirteen (13) (5.5%) patients experienced ATA during follow-up (mean, 21±14 months). Compared with patients without new-onset ATA, patients with new-onset ATA were older (48±18 vs 66±11 years; p<0.001) and had high brain natriuretic peptide (BNP) levels (36±36 vs 177±306 pg/mL; p<0.001). On multivariable analysis, BNP ≥40 pg/mL before ASD closure was associated with new-onset ATA after adjusting for age (OR, 4.91; 95% CI, 1.22-19.8; p=0.025). CONCLUSION: Patients with BNP levels >40 pg/mL before transcatheter ASD closure may have a higher risk of developing new-onset ATA.

Fracture of the delivery balloon shaft during balloon-expandable prosthesis alignment during implantation of an Edwards SAPIEN 3.

The expandable sheath was designed with a lower profile in order to reduce the incidence of vascular complications of transcatheter aortic valve implantation using transfemoral approach. However, once the prosthesis has crossed the sheath, it could be difficult to retrieve it from the body. This is the first case of successful bail-out in an instance of delivery balloon shaft malfunction subsequent to the crossing of an expandable sheath during implantation of an Edwards SAPIEN 3 prosthesis. © 2016 Wiley Periodicals, Inc.

Incidence, predictors, and midterm clinical outcomes of left ventricular obstruction after transcatheter aortic valve implantation.

OBJECTIVES: We aimed to evaluate the incidence and midterm clinical outcomes of left ventricular obstruction (LVO) after transcatheter aortic valve implantation (TAVI). BACKGROUNDS: LVO is occasionally unmasked following valve replacement for severe aortic stenosis. However, little is known about the prevalence and effects of LVO after TAVI. METHODS: A total of 158 patients who underwent TAVI in our center between October 2013 and November 2015 received echocardiographic evaluations at baseline; before hospital discharge; and at 3, 6, and 12 months after TAVI. LVO was defined as a peak pressure gradient >30 mm Hg. RESULTS: Over 1 year of follow-up after TAVI, 21 patients (13.3%) demonstrated postprocedural LVO. The incidence was highest at 3-months follow-up and decreased at 6 months or later. Of the 21 patients with LVO, 20 (95.2%) demonstrated midventricular obstruction (MVO), whereas only 1 (4.8%) showed obstruction of the outflow tract (LVOT) with systolic anterior motion (SAM) of the mitral leaflet. In a multivariate analysis, the LVOT diameter (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.30-0.67; P < 0.001), transvalvular velocity (OR, 2.44; 95% CI, 1.13-5.26; P = 0.023), and the presence of accelerated intraventricular flow at baseline (OR, 6.13; 95% CI, 1.49-25.2; P = 0.012) were associated with the occurrence of LVO. Postprocedural LVO was not associated with midterm all-cause death or heart failure events. CONCLUSION: In patients who underwent TAVI, MVO occurred more often than LVOT obstruction. However, the occurrence of postprocedural LVO was not associated with worsened clinical outcomes in these patients.

Incidence and predictors of coronary obstruction following transcatheter aortic valve implantation in the real world.

OBJECTIVES: Coronary obstruction (CO) is a rare but serious complication of transcatheter aortic valve implantation (TAVI). There are very limited data regarding CO following TAVI. The aim of this study was to evaluate the incidence and outcomes of CO after TAVI and identify the predictors including the valve type. METHODS: Between October 2006 and March 2015, 1,203 TAVI cases were performed in our institution. Of them, 814 cases whose coronary height was measured using computed tomography for screening were analyzed in this study. RESULTS: The Edwards SAPIEN/SAPIEN XT (S/XT) was used in 427 (52.4%) cases, the CoreValve in 265 (32.6%), and the S3 in 122 (15.0%). CO occurred in 8 (1.0%) cases, 1.6% with S/XT, 0.4% with CoreValve, and 0% with S3. All instances of CO occurred at the left coronary artery. The 30-day mortality was significantly higher in cases of CO (37.5% vs. 5.8%, P = 0.010). The frequency of CO tended to be lower in recipients of the CoreValve (0.4%) and S3 (0%) compared with the S/XT (1.6%) (P = 0.188 for CoreValve vs. S/XT, P = 0.022 for S3 vs. S/XT). CONCLUSIONS: CO has poor outcomes and identification of patients at risk of CO to take preventive measures is crucial. The preliminary data showing that the occurrence of CO is low in patients receiving the S3 despite increased prosthesis height need further confirmation. © 2017 Wiley Periodicals, Inc.

Streamlining the learning process for TAVI: Insight from a comparative analysis of the OCEAN-TAVI and the massy registries.

BACKGROUNDS: To facilitate the learning process of transcatheter aortic valve implantation (TAVI) in Japan, unique supporting systems (e.g., on-site proctor and web-based screening systems) have been developed. Nevertheless, little is known about real-world clinical outcomes after TAVI in Japan compared with their European counterparts. METHODS: From the optimized catheter valvular intervention (OCEAN-TAVI, Japan) and the Institut Cardiovasculaire Paris Sud (Massy, France) registries, we evaluated a total of 134 and 178 patients, respectively, who underwent transfemoral TAVI during the same time period. RESULTS: Among the French cohort, about half of the patients (N = 81, 45.5%) were treated with the Edwards SAPIEN XT. Body surface area was significantly smaller in the Japanese cohort, although operative risks for both cohorts were almost the same. A greater percentage of patients in the Japanese cohort were implanted with 23 mm valves compared with the French cohort (73.1% vs. 23.0%, P < 0.001), reflecting the smaller annulus diameter (21.8 ± 1.6 vs. 23.8 ± 2.4 mm, P < 0.001). All-cause 30-day mortality (0% vs. 0.6%, P = 1.000) and 30-day combined safety endpoint based on the Valve Academic Research Consortium 2 (VARC2) criteria (9.7% vs. 11.2%, P = 0.713) were similar when limiting the analysis to patients treated with the Edwards SAPIEN XT. CONCLUSIONS: Despite the unfavorable aortic anatomy of the Japanese patients, their clinical outcomes after transfemoral TAVI were excellent with the same degree of safety as in an experienced European institute. This minimized learning process achieved the use of unique support systems.

Comparison of multislice computed tomography findings between bicuspid and tricuspid aortic valves before and after transcatheter aortic valve implantation.

AIMS: This study sought to compare the multislice computed tomography (MSCT) characteristics of bicuspid aortic valves (BAV) and tricuspid aortic valves (TAV) before and after implantation of the CoreValve (Medtronic, Santa Rosa, California) or the Edwards SapienXT (Edwards Lifesciences, Irvine, CA). METHODS AND RESULTS: From March 2009 to March 2013, a total of 67 TAVI patients who had both pre- and post-procedural MSCT were studied. Eleven patients underwent TAVI in BAV with the CoreValve (n = 6) or SapienXT (n = 5) and 56 patients underwent TAVI in TAV with the CoreValve (n = 38) or SapienXT (n = 18). The BAV group was similar to the TAV group except for a higher pre-procedural mean pressure gradient (53.1 ± 17.4 vs. 48.8 ± 20.4 mm Hg, P = 0.03), a larger annulus perimeter (89.3 ± 9.0 vs. 81.8 ± 8.1 mm, P = 0.03) and a higher aortic valve calcium volume (1262.7 ± 396.0 vs. 556.4 ± 461.9 mm(3) , P < 0.01). In the CoreValve group, post-procedural mean pressure gradient was significantly higher in the BAV group (11.0 ± 2.6 vs. 8.2 ± 2.8 mm Hg, P = 0.04) and a smaller valve area/pre-annulus area ratio was observed at each level of the prosthesis (base of the stent frame 81.7% ± 14.9% vs. 94.7% ± 15.0%, P = 0.06, annulus level 74.3% ± 16.7% vs. 89.9% ± 10.5%, P = 0.03, leaflet level 64.6% ± 13.1% vs. 81.2% ± 13.2%, P < 0.01). This was not observed in the Edwards group. CONCLUSIONS: Compared to TAV, patients with BAV have higher gradients, larger annulus perimeters and more calcified valves. Higher post procedural gradient and valve underexpansion were frequently observed after CoreValve implantation. Further MSCT study is required to demonstrate the efficacy of TAVI in BAV.

Prognostic value of aortic root calcification volume on clinical outcomes after transcatheter balloon-expandable aortic valve implantation.

BACKGROUND: Few data are available about whether aortic root calcification may impact the outcomes after transcatheter aortic valve implantation (TAVI). OBJECTIVES: This study sought to evaluate the impact of aortic root calcification volume on clinical outcome after TAVI with balloon expandable Edwards Sapien XT valve (Edwards Lifesciences, Irvine, California). METHODS: A total of 162 TAVI patients (aged 84.0 [Interquartile Range (IQR) 81.0-84.0] years, Logistic EuroSCORE 14.5 [IQR 9.8-25.1]) with preprocedural MDCT were studied. Aortic root calcification volume was measured by MDCT image and using the dedicated software for aortic valve assessment (the automated 3mensio™ Valves 5.1, sp1, 3mensio Pie Medical Imaging BV, Maastricht, the Netherlands). A valve calcification index (VCI) was defined as calcification volume (mm(3))/body surface area (mm(2)). RESULTS: VCI was significantly higher among patients with 30-day mortality. A VCI threshold of 517.4 (area under the curve 0.69, 95% CI 0.50-0.87, P = 0.03) predicted a higher incidence of annulus rupture (9.1 vs. 0.9%, P = 0.02) and cardiac tamponade (12.7 vs. 1.9%, P < 0.01), lower device success (83.6% vs. 95.3%, P < 0.01) and 30-day survival rate (80.0% vs. 97.2%, P < 0.01). Multivariate logistic regression analysis showed only ejection fraction and VCI were identified as independent predictors of 30-day mortality (Odds ratio 0.948 [95% confidence interval 0.909-0.988], P = 0.012, Odds ratio 1.003 [95% confidence interval 1.001-1.005], P = 0.013, respectively). CONCLUSIONS: Significantly worse acute clinical outcomes after Edwards valve implantation were observed in patients with large amount of aortic annulus calcifications quantitatively measured by dedicated MDCT software. Application of VCI may prove helpful in prediction of clinical outcomes after TAVI.

Impact of pre- and post-procedural anemia on the incidence of acute kidney injury and 1-year mortality in patients undergoing transcatheter aortic valve implantation (from the French Aortic National CoreValve and Edwards 2 [FRANCE 2] Registry).

OBJECTIVES: The relationship between anemia, renal insufficiency, and the outcomes of TAVI patients has not been thoroughly studied. We aimed to evaluate the influence of pre- and post-procedural anemia on the incidence of renal insufficiency, especially AKI, and on the outcomes of TAVI. METHODS: Data from the French national TAVI registry were collected in 3,472 patients who underwent TAVI between January 2010 and December 2012. Of these 2,137 were in the no/mild anemia group, 748 were in the moderate anemia group, and 587 were in the severe anemia group before TAVI. Furthermore, we divided the 3,472 patients into three groups according to post-procedural anemia, measured as post-procedural hemoglobin (Hb) drop: <2 g/dl (n=1,633, group 1), 2 to <4 g/dl (n=1,458, group 2), and >4 g/dl (n = 381, group 3). Procedure and outcome variables were compared. RESULTS: Increased severity of anemia before TAVI was associated with significantly different rates of 1-year mortality (15%, 19%, and 24%, P<0.01), with similar differences in the incidence of AKI (5%, 8%, and 10%, P<0.01). Increased severity of Hb drop was associated with significantly different rates of 1-year mortality (16%, 18%, and 23%, P<0.01), and with similar differences in the incidence of AKI (6%, 7%, and 10%, P=0.04). Both pre- and post-procedural anemia were predictors of the incidence of AKI (OR 1.82, P<0.01; OR 1.82, P<0.01, respectively) and 1-year mortality (HR 1.44, P<0.01; HR 1.50, P<0.01, respectively). CONCLUSIONS: Both pre- and post-procedural anemia were significantly associated AKI and 1-year mortality.

Can we predict postprocedural paravalvular leak after Edwards SAPIEN transcatheter aortic valve implantation?

BACKGROUND: Postprocedural paravalvular leak (PVL) ≥ 2 has been shown to be associated with worse outcomes after transcatheter aortic valve implantation (TAVI). This study sought to identify predictive factors of postprocedural PVL ≥ 2 after TAVI with the Edwards valve. METHODS AND RESULTS: A total of 176 patients with Edwards TAVI (aged 83.4 ± 7.4 years, Logistic EuroSCORE [the Logistic European System for Cardiac Operative Risk Evaluation] 18.8 ± 12.0, transfemoral 54.5%) who had preprocedural multidetector computed tomography (MDCT) were studied. A PVL ≥ 2 was observed in 12.5% of cases. By multivariate analysis, only the valve calcification index (VCI) defined as aortic root calcification volume/body surface area (odds ratio [OR] = 1.002, 95% confidence interval [CI] = 1.001-1.004, P = 0.006) and the valve diameter/the calculated average annulus diameter (CAAD) by MDCT (OR = 0.683, 95% CI = 0.474-0.984, P = 0.041) were identified as independent predictors of postprocedural PVL ≥ 2. A score predicting postprocedural PVL ≥ 2 (PVL score) was determined by allotting one point when the valve diameter/CAAD ratio was <1.055 and one point when VCI was >418.4 mm(3) /m(2) , and summing all points accrued. Area under receiver-operator characteristic curves of PVL score was 0.71 (95% CI = 0.59-0.83, P < 0.01). The incidence of PVL ≥ 2 was 5.3% in patients with a PVL score of 0, 11.8% for a PVL score of 1 and 37.5% for a PVL score of 2. CONCLUSIONS: The only predictors of PVL ≥ 2 after Edwards valve implantation are the valve diameter/CAAD and VCI. The PVL score could prove to be an excellent tool for predicting the risk of PVL.

Usefulness of a Simple Clinical Risk Prediction Method, Modified ACEF Score, for Transcatheter Aortic Valve Implantation.

BACKGROUND: We assessed the predictive accuracy of a simple risk score, modified age, creatinine clearance, ejection fraction (ACEFmodif) score, for outcome of transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: We prospectively included 703 consecutive patients undergoing TAVI. Patients were divided into low, middle and high ACEFmodif tertiles. Increased ACEFmodif score was associated with a significantly higher 1-year mortality rate (22%, 28% and 36%, P<0.01) and higher risk of acute kidney injury (AKI; 10%, 10% and 22%, P<0.01). On multivariate logistic regression analysis, ACEFmodif score was the only independent predictor of AKI. On multivariate Cox regression, ACEFmodif score was an independent predictor of 1-year cumulative mortality. Although the area under curve (AUC) showed that all risk scores poorly predicted the incidence of AKI and 1-year cumulative mortality, ACEFmodif score was more efficient in predicting the incidence of AKI compared with STS, LES and ES II (AUC, 0.61, 0.55, 0.54, 0.57, respectively). Furthermore, ACEFmodif score had similar accuracy in predicting 1-year mortality compared with other risk scores (AUC, 0.61, 0.61, 0.61, 0.61, respectively). CONCLUSIONS: ACEFmodif score may provide useful information for predicting AKI, 30-day and 1-year mortality in patients undergoing TAVI, but these results need further confirmation.

TAVI and Bicuspid Aortic Valve: Check the Inter-Commissural Space!

Transcatheter aortic valve implantation (TAVI) in cases of bicuspid aortic valve (BAV) with a large aortic annulus remains challenging and is rarely performed due to the risk of residual paravalvular aortic leakage. A SAPIEN 3 prosthesis was successfully implanted in two BAV patients each with a relatively large aortic annulus. The New SAPIEN 3 design, coupled with good sealing at the level of the inter-commissural space of the bicuspid valve, seems to account for the efficiency of TAVI for BAV with a large annulus.

Prognostic implications of optimal medical therapy in patients undergoing percutaneous coronary intervention for acute coronary syndrome in octogenarians.

The proportion of elderly acute coronary syndrome (ACS) patients who receive optimal medical therapy (OMT) after percutaneous coronary intervention (PCI) and whether OMT affects their long-term outcomes remain unclear. We retrospectively investigated 405 ACS patients who underwent stent implantation between 2005 and 2009, and compared the outcomes between patients <80 years of age vs. ≥80 years of age. The prescription rate of the recommended medical agents for ACS in both groups during hospitalization and 2 years after admission was also retrieved. Among the enrolled study population, 75 patients (19%) were aged ≥80 years. These elderly patients had a higher 2-year mortality compared with patients aged <80 years group. The prescription rate of beta-blockers, angiotensin-blocking drugs, and statins tended to be lower in patients aged ≥80 years than in those aged <80 years. Furthermore, among patients ≥80 years of age, those who received OMT had better clinical outcome of 2-year mortality compared to those without OMT. Elderly patients with ACS treated by PCI are at substantially higher risk of adverse events than younger patients. However, they are less likely to receive OMT. PCI with OMT might improve the clinical outcomes of elderly ACS patients.

Anatomical variations affect radial artery spasm and procedural achievement of transradial cardiac catheterization.

Transradial cardiac catheterization (TRCC) has unique technical challenges such as access difficulty related to anatomical variations and/or radial artery (RA) spasm. We sought to evaluate the incidence of anatomical variations of the RA and whether they would affect RA spasm and procedural achievement of TRCC. A total of 744 consecutive patients who underwent TRCC were analyzed by routine radial arteriography. Anatomical variations were defined as abnormal origin of the RA and/or radioulnar loop and/or tortuous configuration. RA spasm was defined as >75 % stenosis at first radial arteriography. Overall, anatomical variations were noted in 68 patients (9.1 %), including 39 cases of abnormal origin (5.2 %), 11 cases of radioulnar loop (1.5 %), and 42 cases of tortuous configuration (5.6 %). Transradial procedures failed in 26 patients (3.5 %), and more frequently in patients with anatomical variation than in those with normal anatomy (23.5 % vs 1.5 %, P < 0.001). Importantly, on multivariate analysis the presence of anatomical variation was a distinct predictor of transradial procedure failure (odds ratio (OR) 17.80; 95 % CI 7.55-43.73; P < 0.001). RA spasm was observed in 83 patients (11.2 %), and more frequently in patients with anatomical variation than in those with normal anatomy (35.3 % vs 8.7 %, P < 0.001). Anatomical variation (OR 4.74; 95 % CI 2.61-8.47; P < 0.001) and female gender (OR 2.23; 95 % CI 1.01-4.73; P = 0.041) were distinct predictors of RA spasm. Anatomical variations were observed in 9.1 % of the patients, and strongly correlated with RA spasm and procedural achievement of TRCC.

Does the same lesion index mean the same efficacy and safety profile: influence of the differential power, time, and contact force on the lesion size and steam pops under the same lesion index.

BACKGROUND: The lesion index (LSI) helps predict the lesion size and is widely used in ablation of various types of arrhythmias. However, the influence of the ablation settings on the lesion formation and incidence of steam pops under the same LSI value remains unclear. METHODS: Using a contact force (CF) sensing catheter (TactiCath™) in an ex vivo swine left ventricle model, RF lesions were created with a combination of various power steps (30 W, 40 W, 50 W) and CFs (10 g, 20 g, 30 g, 40 g, 50 g) under the same LSI values (5.2 and 7.0). The correlation between the lesion formation and ablation parameters was evaluated. RESULTS: Ninety RF lesions were created under a target LSI value of 5.2, and eighty-four were developed under a target LSI value of 7.0. In the LSI 5.2 group, the resultant lesion size widely varied according to the ablation power, and a multiple regression analysis indicated that the ablation energy delivered was the best predictor of the lesion formation. To create a lesion depth > 4 mm, an ablation energy of 393 J is the best cutoff value, suggesting a possibility that ablation energy may be used as a supplemental marker that better monitors the progress of the lesion formation in an LSI 5.2 ablation. In contrast, such inconsistency was not obvious in the LSI 7.0 group. Compared with 30 W, the 50-W ablation exhibited a higher incidence of steam pops in both the LSI 5.2 and 7.0 groups. CONCLUSIONS: The LSI-lesion size relationship was not necessarily consistent, especially for an LSI of 5.2. To avoid any unintentional, weak ablation, the ablation energy may be a useful supportive parameter (393 J as a cutoff value for a 4-mm depth) during ablation with an LSI around 5.2. Thanks to a prolonged ablation time, the LSI-lesion size relationship is consistent for an LSI of 7.0. However, it is accompanied by a high incidence of steam pops. Care should be given to the ablation settings even when the same LSI value is used.

Postoperative intravenous patient-controlled analgesia improves pain management after subcutaneous implantable defibrillator implantation.

Objective: Postoperative pain is a major issue with subcutaneous implantable cardioverter defibrillators (S-ICD). In 2020, we introduced intravenous patient-controlled analgesia (IV-PCA) in addition to the conventional, request-based analgesia for postoperative pain control in S-ICD. To determine the effect and safety, we quantitatively assessed the effect of IV-PCA after S-ICD surgery over conventional methods. Methods: During the study period, a total of 113 consecutive patients (age, 50.1 ± 15.5 years: males, 101) underwent a de novo S-ICD implantation under general anesthesia. While the postoperative pain was addressed with either request-based analgesia (by nonsteroid anti-inflammatory drugs, N = 68, dubbed as "PCA absent") or fentanyl-based IV-PCA in addition to the standard care (N = 45, dubbed as "PCA present"). The degree of postoperative pain from immediately after surgery to 1 week were retrospectively investigated by the numerical rating scale (NRS) divided into four groups at rest and during activity (0: no pain, 1-3: mild pain, 4-6: moderate pain, 7-10: severe pain). Results: Although IV-PCA was removed on Day 1, it was associated with continued better pain control compared to PCA absent group. At rest, the proportion of patients expressing pain (mild or more) was significantly lower in the PCA present group from Day 0 to Day 4. In contrast to at rest, a better pain control continued through the entire study period of 7 days. No serious adverse events were observed. A few patients experienced nausea in both groups and the inter-group difference was not found significant. Conclusion: IV-PCA suppresses postoperative pain in S-ICD without major safety concerns.

Association between Mobility of Residual Left Atrial Thrombus and Stroke Severity in Patients with Nonvalvular Atrial Fibrillation.

BACKGROUND: The differences in the characteristics of ischemic stroke associated with a mobile versus nonmobile residual left atrial thrombus (LAT) are unclear. We investigated whether the mobility of an LAT detected by transthoracic echocardiography is associated with the clinical features of stroke. METHODS: This study included 20 consecutive patients with nonvalvular atrial fibrillation who were admitted to our hospital for treatment of acute ischemic stroke and then found to have an LAT on transthoracic echocardiography. The patients were divided into two groups: those with a mobile LAT (Group M) and those with a nonmobile LAT (Group N). The clinical, neuroradiological, and echocardiographic variables were assessed. RESULTS: The LAT was mobile in 11 patients (Group M) and nonmobile in nine patients (Group N). The median National Institutes of Health Stroke Scale score on admission was higher in Group M than N (17 vs. 7, respectively; p=0.196). Four patients in Group M and one in Group N developed in-hospital stroke recurrence (36% vs. 11%, respectively; p=0.319). The prevalence of large vessel occlusion (15 events in Group M and 10 events in Group N, including in-hospital recurrent events) was significantly higher in Group M than N (73% vs. 30%, respectively; p=0.049), which seemed to lead to poorer functional outcomes in Group M than N (ratio of modified Rankin scale score of 0-2 at discharge: 18% vs. 44%, respectively; p=0.336). CONCLUSIONS: The mobility of LAT may affect stroke severity in patients with nonvalvular atrial fibrillation.

Acute coronary syndrome or apical ballooning syndrome?

Apical ballooning syndrome (ABS) is uniquely characterized by the acute onset of transient extensive kinesis of the apical and mid portions of the left ventricle without significant epicardial coronary artery stenosis, accompanied by chest symptoms and electrocardiogram changes similar to those of acute coronary syndrome. We report a case of ABS with severe coronary artery stenosis presenting as acute coronary syndrome after emotional stress. ABS should be considered a cause of left ventricular wall motion abnormalities even if a coronary arteriogram shows severe coronary artery stenosis.

Incidence of periprocedural myocardial infarction and cardiac biomarker testing after percutaneous coronary intervention in Japan: results from a multicenter registry.

Periprocedural myocardial infarction (pMI) is an important complication associated with percutaneous coronary intervention (PCI). However, data on the frequency of biomarker testing and the incidence of pMI remain unclear. Using the multicenter Japan Cardiovascular Database, we identified 2182 patients who underwent PCI without preprocedural cardiac biomarker elevation (silent ischemia, stable angina, or unstable angina without biomarker elevation) from September 2008 to August 2011. Of these, 550 patients (25.2 %) underwent cardiac biomarker testing within 6-24 h after PCI. The incidence of pMI was 2.7 % among all identified patients and 7.5 % among those who underwent cardiac marker testing. Of note, cardiac biomarker testing was performed more frequently than no testing in patients with a higher risk profile such as unstable angina (32.7 vs 24.7 %, P < 0.001), higher symptom scaling (28.2 vs 22.5 %, P = 0.008), urgent or emergent procedures (19.3 vs 15.0 %, P = 0.022 or 4.2 vs 1.0 %, P < 0.001, respectively), and type C lesion (31.3 vs 25.2 %, P = 0.006). Presentation with silent ischemia (odds ratio = 1.51, 95 % confidence interval (CI) 1.16-1.97) and nonemergent PCIs (odds ratio = 3.45, 95 % CI 1.79-6.67) were associated with no postprocedural cardiac biomarker testing. The real-world multicenter PCI registry in Japan revealed an incidence of 2.7 % for pMI; however, cardiac biomarkers were assessed in only 25.2 % of patients after PCI. The results suggest an underuse of postprocedural biomarker testing and room for procedural quality improvement, particularly in cases of silent ischemia and nonemergent cases.

Progression of coronary artery calcification after radiation therapy for esophageal cancer.

BACKGROUND: Advances in cancer treatment have resulted in increased attention toward potential cardiac complications, especially following treatment for esophageal cancer, which is associated with a risk of coronary artery disease. As the heart is directly irradiated during radiotherapy, coronary artery calcification (CAC) may progress in the short term. Therefore, we aimed to investigate the characteristics of patients with esophageal cancer that predispose them to coronary artery disease, CAC progression on PET-computed tomography and the associated factors, and the impact of CAC progression on clinical outcomes. METHODS: We retrospectively screened 517 consecutive patients who received radiation therapy for esophageal cancer from our institutional cancer treatment database between May 2007 and August 2019. CAC scores were analyzed clinically for 187 patients who remained by exclusion criteria. RESULTS: A significant increase in the Agatston score was observed in all patients (1 year: P  = 0.001*, 2 years: P  < 0.001*). Specifically for patients receiving middle-lower chest irradiation (1 year: P  = 0.001*, 2 years: P  < 0.001*) and those with CAC at baseline (1 year: P  = 0.001*, 2 years: P  < 0.001*), a significant increase in the Agatston score was observed. There was a trend for a difference in all-cause mortality between patients who had irradiation of the middle-lower chest ( P  = 0.053) and those who did not. CONCLUSION: CAC can progress within 2 years after the initiation of radiotherapy to the middle or lower chest for esophageal cancer, particularly in patients with detectable CAC before radiotherapy initiation.