Differences in quality of life improvement with pulmonary vein isolation alone vs. more extensive ablation of persistent atrial fibrillation: insights from the EARNEST-PVI trial

Background

Improving the quality of life (QoL) is one of the main purposes of catheter ablation (CA) of persistent atrial fibrillation (AF). QoL improvement in persistent AF patients has not been fully clarified. The EARNEST-PVI trial was a multi-center randomized trial comparing clinical outcomes of pulmonary vein isolation (PVI) alone and more intensive ablation in addition to PVI including complex fractionated atrial electrogram (CFAE) and linear ablation (PVI plus).

Purpose

To investigate the QoL change after persistent AF ablation and the differences between the PVI-alone strategy and the PVI plus strategy.

Methods

In the EARNEST-PVI trial, patients with persistent AF who underwent an initial catheter ablation (n=512) were randomly assigned in a 1:1 ratio to either PVI alone or PVI plus. Quality of life was assessed at baseline and at 12 months after ablation for AF using the 36-Item Short Form Health Survey. Scores were also converted to a physical health component summary (PCS), a mental health component summary (MCS) and a role/social component summary (RCS).

Results

In the EARNEST-PVI trial, the PVI alone strategy was associated with higher recurrence rate compared with the PVI plus additional ablation strategy. After excluding 68 patients for whom preoperative or postoperative QoL assessment was not available, 222 patients were evaluated respectively. Overall, significant improvements in PCS (46.2±11.4 to 48.7±11.4]), MCS (50.1±8.8 to 54.3±8.6) and RCS (44.6±13.3 to 48.6±11.3) occurred 12 months after ablation (P<0.001, respectively). Although significant QoL improvement occurred in both PVI alone and PLI plus strategies, the changes in PCS was greater in the PVI-plus than that in PVI-alone (3.5±10.3 vs 1.5±10.6, P=0.04).

Conclusions

Ablation for persistent atrial fibrillation improved both physical and mental quality of life. The PVI-plus strategy showed greater improvement in physical QoL.

Funding Acknowledgement

Type of funding sources: None. QoL improvement

Long-term prognostic value of the combination of malnutrition and fib-4 index in patients admitted with acute decompensated heart failure

Background

Malnutrition is associated with increased mortality risk in patients with acute decompensated heart failure (ADHF). Cardiohepatic interactions have been a focus of attention among heart failure. It was reported that liver stiffness assessed by non-invasive fibrosis marker such as Fibrosis-4 (FIB4) index provide prognostic information in ADHF patients. However, there is no information available on the long-term prognostic value of the combination of malnutrition and FIB4 index in patients admitted for ADHF.

Methods and results

We studied 294 patients admitted for ADHF, who were discharged with survival. Nutritional status was evaluated by Geriatric Nutritional Risk Index (GNRI) calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × BMI/22, and malnutrition was defined as GNRI <92. FIB4 index was calculated by the formula: age (yrs) × AST[U/L] / (platelets [103/μL] × (ALT[U/L])1/2), and abnormal FIB4 index was defined as >2.67. During a mean follow-up period of 4.3±3.3 yrs, 94 patients had all-cause death. At multivariate Cox regression analysis, GNRI and FIB4 index were significantly associated with the total mortality, independently of prior heart failure hospitalization, systolic blood pressure, and serum creatinine level. Patients with malnutrition and abnormal FIB4 index had a significantly higher risk of the total mortality than those with either and none of them (49% vs 32% vs 20%, p<0.0001, respectively).

Conclusions

The combination of malnutrition and FIB4 index might be useful for stratifying ADHF patients at higher risk for the total mortality.

Funding Acknowledgement

Type of funding sources: None.

Gender differences in the impact of plasma xanthine oxidoreductase activity on coronary artery spasm

Background

It has been reported that decreased nitric oxide bioavailability due to increased reactive oxygen species (ROS) is one of the most important causes of coronary artery spasm (CAS). Xanthine oxidoreductase (XOR) is the rate-limiting enzyme for uric acid (UA) production and plays a pivotal role in generating ROS. It was reported that the gender differences exist in the impact of serum UA levels on cardiovascular risks. We previously demonstrated that increased plasma XOR activity is significantly associated with the incidence of CAS. However, the gender differences in the impact of plasma XOR activity on CAS remain unclear.

Purpose

The aim of this study was to examine the gender differences in the clinical impact of plasma XOR activity on CAS.

Methods

We investigated plasma XOR activity in 132 patients suspected for CAS (male, n=78; female, n=54), and underwent intracoronary acetylcholine provocation test. XOR activity assay was performed using stable isotope-labeled substrate and liquid chromatography-triple quadrupole mass spectrometry. Provoked CAS was defined as total or subtotal occlusion (≥90%) with accompanying symptoms of chest pain and/or ischemic ST-segment changes on the electrocardiogram. We excluded the patients who had significant coronary artery stenosis (≥50%) and/or were taking XOR inhibitors.

Results

Plasma XOR activity was significantly lower in female compared with male patients (30.3 pmol/h/mL, interquartile range (IQR) 22.8–42.7 vs. 51.7 pmol/h/mL, IQR 34.7–101.8; P<0.001). CAS was provoked in 36 male patients and 17 female patients, and they each had significantly higher plasma XOR activity compared with those without, respectively. Multivariate logistic regression analysis showed that plasma XOR activity was independently associated with the incidence of CAS in both genders after adjustment for confounding factors. The optimal cut-off values for predicting CAS were lower in female than those in male patients (52.3 vs. 91.6 pmol/h/mL). Multivariate analysis demonstrated that female patients with high XOR activity (≥52.3 pmol/h/mL; odds ratio [OR] 22.6, P<0.001) exhibited a higher incidence of CAS compared with that in male patients (≥91.6 pmol/h/mL; OR 8.2, P<0.001).

Conclusions

Plasma XOR activity was an independent predictor for the incidence of CAS in both genders. The impact of plasma XOR activity on CAS was stronger in female patients than in male patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Cribriform carcinoma in the lymph nodes is associated with distant metastasis, recurrence, and survival among patients with node-positive colorectal cancer

Cribriform lymph node pattern is an independent risk factor for metachronous or synchronous distant metastasis in patients with stage III and IV node-positive colorectal cancer. Multivariable analysis in patients with stage III disease indicated that the cribriform pattern of carcinoma in the lymph nodes was an independent risk factor for recurrence and survival. Kaplan–Meier analysis demonstrated that the group with stage III cribriform-type lymph node carcinoma had shorter recurrence-free and overall survival times than the stage III group with the tubular type (P < 0.001).

The feasibility of a newly developed local network system for cardiac rehabilitation (the CR-GNet) in disease management and physical fitness after acute coronary syndrome

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Grant-in-aid from.jpgu Prefecture

Background

The newly developed Cardiac Rehabilitation.jpgu Network (CR-GNet) has been implemented to create a regional alliance network and to provide periodic follow-up examinations to enhance the disease management in patients with cardiovascular disease. The effectiveness of a network like this support system has not yet been evaluated in Japan.

Purpose

We aimed to examine the feasibility of the CR-GNet in disease management, assisting patients in attaining physical fitness and its impact on long-term outcomes after acute coronary syndrome (ACS).

Methods

We enrolled 47 patients with ACS in the CR-GNet between February 2016 and September 2019; of these, 37, 29, and 21 patients underwent follow-up assessments for exercise capacity (peak oxygen uptake) at 3 months, 6 months, and 1 year after discharge, respectively. Major adverse cardiac events (MACE) were defined as the composite of death from cardiac causes, cardiac arrest, myocardial infarction, and rehospitalization due to unstable or progressive angina. MACE were compared with controls who were not registered in the CR-GNet.

Results

The coronary risk factors, except blood pressure, improved at 3 and 6 months, and 1 year after discharge. These risk factors in each patient significantly reduced from 2.9 at admission to 1.6, 1.4, and 1.9 at 3 months, 6 months, and 1 year after discharge (p < 0.05), respectively. Peak oxygen uptake was significantly higher at 3 months, 6 months, and 1 year after discharge to 17.5 ± 4.9 ml/kg/min, 17.9 ± 5.1 ml/kg/min, and 17.5 ± 5.5 ml/kg/min, respectively, than that at discharge (14.7 ± 3.6 ml/kg/min) (p < 0.05). During follow-up, there was no significant difference; MACE did not occur in any patients in the CR-GNet but occurred in controls.

Conclusions

The CR-GNet is a feasible option for long-term management of ACS patients. The prognostic impact of the CR-GNet needs further investigation with a larger sample size and longer follow-up.

Table1 At admission 3 months 6 months 1 year Average number 2.9 1.6* 1.4** 1.9*** † Average number of coronary risk factors for all patients (n = 21) p = 0.004, vs. at admission; **p = 0.001, vs. at admission; ***p = 0.011, vs. at admission; †p = 0.035, vs. at 6 months

MHD simulation of supersonic FRC merging corrected by non-invasive magnetic measurements

In this study, a newly developed correction method with external magnetic measurements for the magnetohydrodynamics (MHD) simulation of the collisional merging formation of a field-reversed configuration (FRC) realized the estimation of the internal structure of the FRCs without invasive internal measurements. In the collisional merging formation of FRCs, an FRC is formed via merging of two initial FRC-like plasmoids at supersonic/Alfvénic velocity. An invasive diagnostic may also interfere with the collisional merging formation process. A two-dimensional resistive MHD simulation was conducted to evaluate the global behavior and internal structure of FRCs in the collisional merging formation process without invasive measurements. This code simulated the initial formation and collisional merging processes of FRCs including discharge circuits. However, the translation velocity and the pressure of initial FRCs did not simultaneously agree with the experimental values because the magnetic pressure gradient in each formation region could not be reproduced without the artificial adjustment of the initial condition. The experimentally measured current distribution was given as the initial condition of the circuit calculation in the developed correction method. The initial FRCs were successfully translated at the translation velocity and plasma pressure in the corrected simulation, both of which were equivalent to the experiments. The properties of the merged FRCs in the experiments such as volume, total temperature, and average electron density were reproduced in the corrected simulation. The detailed radial profile of the internal magnetic field of the FRC was also measured and found to agree very well with the simulation results.

Internal magnetic measurement in collisional-merging process of a field-reversed configuration

An internal magnetic probe array has been developed to observe the three components of the magnetic field simultaneously in the vicinity of the collision surface of two colliding plasmoids at supersonic/Alfvénic velocity. Collisional-merging formation of a field-reversed configuration (FRC) has been conducted in the (FRC Amplification via Translation-Collisional Merging) device at Nihon University. Significant plasma heating and an increase in trapped poloidal magnetic flux have been observed during/after the collisional-merging process in the FAT-CM device. In this dynamic formation process, two FRC-like plasmoids formed by a field-reversed theta-pinch method collide in the middle of the confinement chamber at a relative speed of 200-400 km/s. Therefore, the excited shockwave is considered as one of the heating mechanisms. The developed probe array installed in the middle of the confinement chamber observes the internal structure of the magnetic field. The probe consists of 12 sets of three-axis chip inductors arranged at intervals of 40 mm. The measurement position can be varied in the radial direction. In the single translation and collisional-merging experiment, the internal magnetic probe measures the magnetic field's radial distribution with a high time resolution under noise.

Fluorescent Cytochemical Detection of Polyphosphates Associated with Human Platelets

Polyphosphate (polyP) is released from activated platelets and activates the intrinsic coagulation pathway. However, polyP may also be involved in various pathophysiological functions related to platelets. To clarify these functions, we established a cytochemical method to reproducibly visualize polyP in platelets. Platelets obtained from healthy non-smoking donors were suspended in phosphate-buffered saline and quickly immobilized on glass slides using a Cytospin. After fixation and membrane permeabilization, platelets were treated with 4′,6- diamidino-2-phenylindole (DAPI) and examined using a fluorescence microscope with a blue-violet excitation filter block (BV-2A). Fixed platelets were also subjected to immunocytochemical examination to visualize serotonin distribution. Under the optimized conditions for polyP visualization, immobilized platelets were fixed with 10% neutral-buffered formalin for 4 h or longer and treated with DAPI at a concentration of 10 µg/mL in 0.02% saponin- or 0.1% Tween-20-containing Hanks balanced salt solution as a permeabilization buffer for 30 min at room temperature (22–25 °C). Based on the results obtained by using activated platelets, treatment with alkaline phosphatases, and serotonin release, the DAPI⁺ targets were identified as polyP. Therefore, this cytochemical method is useful for determining the amount and distribution of polyP in platelets.

Distribution and quantification of activated platelets in platelet-rich fibrin matrices

Platelet-rich fibrin (PRF) has been widely applied in regenerative therapy owing to its simple preparation protocol. To date, the original protocol for preparing leukocyte-rich (L)-PRF has been modified to produce derivatives such as advanced (A)-PRF, concentrated growth factors (CGF), and horizontal (H)-PRF. However, these derivatives have not been rigorously compared to explore possible differences. We previously developed and validated a nondestructive near-infrared (NIR) imaging method to quantitatively examine the platelet distribution in PRF matrices. To further evaluate the characteristics of platelets in PRF, we herein examined the distribution of activated platelets. Four types of PRF matrices were prepared under different centrifugal conditions from blood samples obtained from the same healthy donors. After fixation and compression, the matrices were stained immunohistochemically without sectioning and visualized using an NIR imager. Qualitative morphological analysis revealed that whole platelets were distributed widely and homogeneously in H-PRF and A-PRF, but localized along the distal tube surface in L-PRF and CGF. Activated platelets were distributed as were whole platelets in A-PRF, L-PRF, and CGF, but localized mainly in the "buffy coat" region in H-PRF. Quantitative analysis revealed that there was no significant difference in the ratio of activated to whole platelets between PRF derivatives. These findings suggest that platelet activation is similarly induced in fibrin matrices regardless of centrifugal speed or rotor angulation. However, only the H-PRF group was distinguishable from the other PRF derivatives in terms of activated platelet distribution.

Platelet adhesion on commercially pure titanium plates in vitro III: effects of calcium phosphate-blasting on titanium plate biocompatibility

BACKGROUND

Platelet-rich plasma (PRP) is often used to improve surface biocompatibility. We previously found that platelets rapidly adhere to plain commercially pure titanium (cp-Ti) plates in the absence, but not in the presence, of plasma proteins. To further expand on these findings, in the present study, we switched titanium plates from a plain surface to a rough surface that is blasted with calcium phosphate (CaP) powder and then examined platelet adhesion and activation.

METHODS

Elemental distribution in CaP-blasted cp-Ti plates was analyzed using energy-dispersive X-ray spectroscopy. PRP samples prepared from anticoagulated blood samples of six healthy, non-smoking adult male donors were loaded on CaP-blasted cp-Ti plates for 1 h and fixed for examination of platelet morphology and visualization of PDGF-B and platelet surface markers (CD62P, CD63) using scanning electron microscopy and fluorescence microscopy. Plain SUS316L stainless steel plates used in injection needles were also examined for comparison.

RESULTS

Significant amounts of calcium and phosphate were detected on the CaP-blasted cp-Ti surface. Platelets rapidly adhered to this surface, leading to higher activation. Platelets also adhered to the plain stainless surface; however, the levels of adhesion and activation were much lower than those observed on the CaP-blasted cp-Ti plate.

CONCLUSIONS

The CaP-blasted cp-Ti surface efficiently entraps and activates platelets. Biomolecules released from the activated platelets could be retained by the fibrin matrix on the surface to facilitate regeneration of the surrounding tissues. Thus, PRP immersion could not only eliminate surface air bubbles but also improve the biocompatibility of the implant surface.

Association of Education and Depressive Symptoms with Tooth Loss

Previous evidence suggests the association of lower educational attainment and depressive symptoms with tooth loss. The hypothesis of this study was that these factors may exacerbate the effect on tooth loss beyond the sum of their individual effects. We aimed to clarify the independent and interactive effects of educational attainment and depressive symptoms on the number of missing teeth among community residents. Cross-sectional data of 9,647 individuals were collected from the general Japanese population. Dental examination was conducted by dentists. Educational attainment was categorized into 3 levels based on the number of educational years: ≤9, >9 to ≤12, and >12 y. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess depressive symptoms; a total score of ≥16 and/or the use of medications for depression indicate the presence of depressive symptoms. In the multivariate analysis with adjustment for conventional risk factors, educational attainment was identified as a determinant of the number of missing teeth (>9 to ≤12 y of education: coefficient = 0.199, 95% confidence interval [CI], 0.135 to 0.263, P < 0.001; ≤9 y of education: coefficient = 0.318, 95% CI, 0.231 to 0.405, P < 0.001: reference, >12 y of education). An analysis that included interaction terms revealed that the relationship between "≤9 y of education" and the number of missing teeth differed depending on the depressive symptoms, indicating a positive interactive association (coefficient for interaction = 0.198; 95% CI, 0.033 to 0.364, P for interaction = 0.019: reference, >12 y of education). Our study suggests the presence of a significant association between educational attainment and tooth loss, as well as a partial interactive association between "≤9 y of education" and "depressive symptoms" in the general Japanese population.

Hyperuricemia impaired nitric oxide bioavailablity and deteriorated pulmonary arterial hypertension via a uric acid transporter, URATv1 in xanthine oxidoreductase (XOR)-independent manner

Background

Hyperuricemia occurs in approximately 80% in patients with pulmonary arterial hypertension (PAH) and is positively correlated with pulmonary arterial pressure (PAP). It has been reported that uric acid (UA) reduced endothelium derived nitric oxide (NO) production in porcine pulmonary arterial endothelial cells (PAEC). However, the effects of UA and xanthine oxidoreductase (XOR), catalytic enzyme of UA, on the development of PAH have not been fully elucidated.

Purpose

We examined the followings; (1) the effects of hyperuricemia on the endothelial function and the development of PAH in rats (2) the therapeutic effects of UA transporter inhibitor on PAH in rats, and (3) the role of XOR in PAH in mice.

Methods

We used normal and 5-wk Sugen5416/Hypoxia/Normoxia-exposed (SU/Hx/Nx) rats. Gene expression levels of URATv1, a UA transporter, were measured by RT-PCR. We determined the isometric tension of PA rings isolated from normal rats. The study with the isolated perfused lung preparation was performed in SU/HX/Nx rats. To investigate the chronic effect of UA on the development of PAH, hyperuricemia was induced by the administration of 2% oxonic acid (OA) in diet for 6-wk. Benzbromarone (BBR, 10mg/kg/day, diet, from weeks 0 to 5), a URATv1 transporter inhibitor, was administered in the SU/Hx/Nx-rats with or without 2%OA. To examine the role of XOR in PAH, XOR+/− and wild type (WT) mice were exposed to 3-wk Nx or Hx (10% O2).

Results

The mRNA of URATv1 was detected in the normal lungs. Isometric tension study showed that UA (8 mg/dl) inhibited acetylcholine-induced vasorelaxation. In perfused lung preparations, UA acutely increased estimated PVR in a dose-dependent manner (1.6–16.0mg/dl) with reducing cGMP levels in the lungs. BBR significantly attenuated the pressor response to UA. UA levels in the plasma and the lung tissues were significantly elevated in SU/Hx/Nx-rats with 2%OA (normal vs. vehicle vs. 2%OA, plasma: 0.24±0.01 vs. 0.80±0.14 and 1.44±0.17 mg/dl; lung tissues: 68±3 vs. 142±3 and 377±46 pmol/g tissue). They exhibited further elevation of right ventricle systolic pressure (RVSP) (31±2 vs. 72±6 vs. 101±3 mmHg) and Ea (a marker of RV afterload) (0.24±0.04 vs. 0.97±0.15 vs. 2.36±0.49 mmHg/μL) with the exacerbation of occlusive lesions of PAs. BBR had no changes in the UA levels in the plasma (1.93±0.30 mg/dL), but significantly reduced the UA levels in the lung tissues (101±10 pmol/g tissue) and attenuated the increase in RVSP (53±8mmHg) and Ea (0.21±0.05 mmHg/mL) in the SU/Hx/Nx-rats with 2%OA. On the other hand, BBR had no effects on RVSP (76±7 mmHg) and Ea (0.91±0.15 mmHg/mL) in the SU/Hx/Nx-rats without 2%OA. There were no significant differences in RVSP between XOR+/− mice with Hx and WT with Hx (26±2 vs. 26±2 mmHg).

Conclusions

Hyperuricemia itself impairs endothelial function and deteriorates PAH via URATv1 in a XOR-independent manner. UA can be a novel therapeutic target for PAH.

Funding Acknowledgement

Type of funding source: None

Elevated serum carboxy-terminal telopeptide of type I collagen predicts clinical outcome in patients with acute coronary syndrome who underwent percutaneous coronary intervention

Introduction

Serum carboxy-terminal telopeptide of type I collagen (I-CTP) is a collagen degradation product of type I collagen in the extracellular matrix of the heart, blood vessels, and bone. The serum levels of I-CTP were reportedly a predictive marker for cardiac remodeling after acute myocardial infarction. However, it remains unclear whether I-CTP can predict poor clinical outcome in patient with acute coronary syndrome (ACS).

Purpose

The aim of this study was to investigate the association between serum levels of I-CTP and clinical outcome in patients with ACS.

Methods

Serum levels of I-CTP were measured in 200 patients with ACS who underwent percutaneous coronary intervention (PCI). All patients were prospectively followed during the median follow-up period of 1312 days with the end point of major adverse cardiovascular events (MACE). We divided the patients into tertiles according to serum I-CTP level: low I-CTP group (≤4.4 ng/ml, n=72), middle I-CTP group (4.4–6.4 ng/ml, n=65), and high I-CTP group (≥6.5 ng/ml, n=63).

Results

There were 44 MACE, including 24 all-cause death and 9 rehospitalization due to heart failure. I-CTP was significantly higher in patients with MACE than those without (4.90 [interquartile range (IQR): 3.80–6.38] ng/ml vs. 6.65 [IQR: 5.00–10.08] ng/ml, p&lt;0.001). Kaplan-Meier analysis demonstrated that patients in the highest tertile of I-CTP had the greatest risk of MACE. In a univariate analysis, age, Albumin, estimated glomerular filtration rate (eGFR), low-density lipoprotein cholesterol (LDL-C), brain natriuretic peptide (BNP), high-sensitivity C-reactive protein (hsCRP) and I-CTP were significant predictors of MACE. A multivariate Cox proportional hazard analysis showed that the high I-CTP group had a higher risk for MACE (Hazard ratio [HR] 2.6, p=0.049) compared with the low I-CTP group after adjusting for confounding factors.

Conclusions

I-CTP was significantly associated with MACE, suggesting that I-CTP could be a reliable marker for clinical outcome in patients with ACS who underwent PCI.

Figure 1

Funding Acknowledgement

Type of funding source: None