Effects of PCSK9 Inhibitor on Favorable Limb Outcomes in Patients with Chronic Limb-Threatening Ischemia

Aim: The aim of this study was to examine the effects of evolocumab on favorable limb events in patients with chronic limb-threatening ischemia (CLTI).

Methods: A single-center, prospective observational study was performed on 30 patients with CLTI. The subjects were divided into 2 groups based on evolocumab administration: evolocumab-treated (E) group ( n =14) and evolocumab non-treated (non-E) group ( n =16). The primary outcome was 12-month freedom from major amputation. The secondary outcomes were 12-month amputation-free survival (AFS), overall survival (OS), and wound-free limb salvage. The mean follow-up period was 18±11 months.

Results: No significant difference was detected between the two groups for the 12-month freedom from major amputation (log-rank p =0.15), while the 12-month AFS rate was significantly higher in the E group than that in the non-E group (log-rank p =0.02). The 12-month OS rate in the E group was shown a tendency for improvement, as compared with that in the non-E group (log-rank p =0.056). Evolocumab administration was not associated with a significant change in freedom from major amputation (HR, 0.23, 95% CI, 0.03-2.07, p =0.19). However, evolocumab administration was related to a tendency for improvement of AFS and OS (HR, 0.13, 95% CI, 0.02-1.06, p =0.056; HR, 0.16, 95% CI, 0.02-1.37, p =0.09, respectively). Moreover, The E group had a higher proportion of wound-free limb salvage at 12 months (92% vs. 42%, p =0.03).

Conclusion: Evolocumab administration was associated with a better AFS outcome in patients with CLTI. Long-term administration of evolocumab over 12 months contributed to improving proportion of wound-free limb salvage.

A Patient with a Large Basilar Artery Aneurysm in Whom Coil Embolization Was Performed by Protruding an LVIS into the Aneurysmal Neck in a Barrel-like Shape and Preserving a Branch Vessel

OBJECTIVE

We report a case of a low-profile visualized intraluminal support device (LVIS) being deployed and protruded into an aneurysmal neck in a barrel-like shape to perform dense coil embolization while preserving the branch vessel from the aneurysmal dome in order to prevent aneurysmal enlargement.

CASE PRESENTATION

A 74-year-old woman had a recurrent large cerebral aneurysm at the bifurcation of the basilar artery and the left superior cerebellar artery (SCA). Therefore, an LVIS was deployed from the left posterior cerebral artery to the basilar artery and protruded into the aneurysmal neck in a barrel-like shape to increase its metal coverage ratio. As the barrel-shaped protruding LVIS served as a scaffold to support the coils, dense coil embolization was performed while preserving the SCA branching from the aneurysmal dome. Images obtained at 6 months and 1 year after the embolization confirmed preservation of the SCA and prevention of aneurysmal enlargement.

CONCLUSION

Protruding the LVIS into an aneurysmal neck in a barrel-like shape is a technique that may help preserve the branch vessel and facilitate dense coil embolization.

Effects of acute angle, proximal bending, and distal bending in the deployment vessels on incomplete low-profile visualized intraluminal support (LVIS) expansion: an in vitro study

BACKGROUND

A low-profile visualized intraluminal support (LVIS) device may incompletely expand during stent deployment in tortuous vessels. However, the cause of incomplete expansion remains uninvestigated. We aimed to examine in vitro the factors causing incomplete expansion in LVIS deployment by using various vessel models.

METHODS

A linear model group was created by connecting linear silicone tubes (inner diameter 4 mm) at both sides of the LVIS deployment vessel (inner diameter 4 mm) with different curvature angles of 10-140° at 10° intervals. For comparison, proximal and distal bending model groups were created, both with 90° bending on the proximal/distal larger curvature side of the deployment vessel. A single operator macroscopically deployed an LVIS (4.5×32 mm) four times in each model and 56 times in each group.

RESULTS

In each model group the LVIS deployment vessel with a narrow curvature angle incompletely expanded. Incomplete expansion occurred significantly more frequently in the distal bending model group (34%, 19/56) compared with that in the linear model group (14.3%, 8/56; p<0.001), as well as in the proximal bending model group (59%, 33/56) compared with that in the distal bending model group (p<0.05). Compared with the linear model group, the proximal bending model group had a significantly reduced angle between the LVIS and the direction of the LVIS pushing force, but no significant change was found in the distal bending model group compared with that in the linear model group.

CONCLUSIONS

Factors such as acute angle, distal bending, and proximal bending of the deployment vessel can cause incomplete LVIS expansion.

Idiopathic right ventricular arrhythmias requiring additional ablation from the left-sided outflow tract: ECG characteristics and efficacy of an anatomical approach

INTRODUCTION

Despite the characteristic electrocardiogram (ECG) findings of early activation during ventricular tachyarrhythmias (VAs) and/or excellent pacemapping in the right ventricular outflow tract (RVOT), some VAs may require additional, left-sided ablation for a cure.

METHODS AND RESULTS

This study included five patients with idiopathic VAs whose QRS morphologies were highly suggestive of an RVOT origin. The ECG characteristics and intracardiac electrocardiograms during catheter ablation were assessed. In all patients, the clinical VAs had an LBBB QRS morphology and inferior axis with a precordial R/S transition through leads V3-V5, and negative components in lead I. The earliest activation during the VAs (local electrogram-QRS interval = -34 ± 6.8 ms) and excellent pacemapping were obtained at the posterior portion of the RVOT just beneath the pulmonary valve. However, ablation at those sites failed, and the QRS morphology of the VAs changed. During left-sided OT mapping, the earliest activation was found at sites just contralateral to the initially ablated sites of the RVOT (junction of the left and right coronary cusps = 2, left coronary cusp = 3). In spite of the late activation time and poor pacemapping scores, catheter ablation at those sites cured the VAs. Those successful sites were also near the transitional zone from the great cardiac vein to the anterior interventricular vein (GCV-AIV).

CONCLUSIONS

Some VAs, highly suggestive of having RVOT origins, require catheter ablation in the left-sided OT near the initially ablated RVOT site. Those VAs have the same ECG characteristics and might have intramural origins in the superobasal LV surrounded by the RVOT, LVOT, and GCV-AIV.

Activatable Fluorescence Imaging of Macrophages in Cerebral Aneurysms Using Iron Oxide Nanoparticles Conjugated With Indocyanine Green

Background and Purpose

Chronic inflammation is involved in the formation and enlargement of cerebral aneurysms (CAs), with macrophages playing a key role in the process. The present study evaluated visualization of macrophages present in CAs using an activatable fluorescent probe (IONP-ICG) comprising an iron oxide nanoparticles (IONPs) conjugated with indocyanine green (ICG).

Methods

IONP-ICG was intravenously administered to 15-week-old CA model rats (n = 8), and ex vivo near-infrared fluorescence (NIRF) imaging and histological assessment of exposed CAs and cerebral arteries were performed 48 h later. Similar evaluations were performed in the control group, which included CA model rats given IONPs or ICG (n = 8 each).

Results

ICG-derived NIRF signals were detected in three IONP-ICG group rats but not in IONP or ICG control groups. Among the three rats that exhibited signals, NIRF signal accumulation was observed in the CA of two rats and at the site of hemodynamic stress in the left posterior cerebral artery in one rat. Histologically, NIRF signals correlated strongly with macrophage localization. A total of 13 CAs formed in the IONP-ICG group. The number of macrophages in the CA wall was significantly greater in the two CAs that exhibited NIRF signals compared to the remaining 11 CAs that did not (P = 0.037). Moreover, all 11 CAs that did not exhibit NIRF signals were iron-negative, while the two CAs that exhibited NIRF signals were both iron-positive (P = 0.013).

Conclusion

NIRF imaging using an activatable IONP-ICG probe is feasible for detecting the macrophage-rich regions in CAs and the cerebral artery wall, which is considered an early lesion in the process of CA formation.

Femoral vascular complications after catheter ablation in the current era: The utility of computed tomography imaging

BACKGROUND

Few studies have examined the characteristics of catheter ablation vascular complications, and recently physicians increasingly use computed tomography angiography (CTA) for diagnosing.

OBJECTIVE

We sought to investigate the incidence of femoral vascular complications in catheter ablation and factors associated with complications in the current era.

METHODS

This single-center observational study consisted of 311 consecutive (atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia, and ventricular arrhythmias in 222 [71.4%], 7 [2.3%], 43 [13.8%], and 39 [12.5%]) patients who underwent catheter ablation. The detailed patient data and clinical outcomes were obtained from the medical records.

RESULTS

Emergent CTA was performed in a total of 8 (2.6%) patients at a median of 4.5 (2.0-12.5) days postprocedure, and the precise diagnosis was obtained in all. Among them, pseudoaneurysms, arteriovenous fistulae (AVF), and actively bleeding hematomas were identified in two, one, and one patient, respectively, and all required readmissions after discharge. AVF was diagnosed by a Doppler ultrasound examination in another patient. In total, 5 (1.6%) patients exhibited major femoral vascular complications including two pseudoaneurysms, two AVFs, and one active bleeding hematoma. The pseudoaneurysms and AVFs were successfully eliminated by direct compression, and extravasation from the femoral circumflex artery required coil embolization. Antiplatelet therapy and the use of larger arterial sheaths (≥7-Fr) increased the major femoral arterial complications, but atrial fibrillation ablation under uninterrupted anticoagulation therapy or the use of larger venous sheaths did not.

CONCLUSION

Vascular complications are still not negligible procedure-related complications during catheter ablation in the current era. CTA provides a rapid and precise diagnosis for optimal treatment strategies.

Two Patients Who Underwent Emergency Stenting for Iatrogenic Cervical Internal Carotid Artery Dissection during Thrombectomy

Objective

Iatrogenic artery dissection during reperfusion therapy is one of the complications causing a poor prognosis. We report two cases of emergent stent placement for iatrogenic cervical carotid artery dissection during reperfusion therapy for acute ischemic stroke.

Case Presentation

Two patients, a 77-year-old woman and a 77-year-old man, were diagnosed with acute major cerebral artery occlusion, and underwent reperfusion therapy. The iatrogenic internal carotid artery dissection was caused by derivation of a 6-Fr catheter and 0.014-inch wire in the tortuous cervical internal carotid artery, and emergent stent placement was performed. Recanalization was confirmed and no deterioration caused by the iatrogenic dissection was found.

Conclusion

In patients in whom cerebral infarction is localized on MRI, additional stent placement may be effective for preventing adverse events caused by iatrogenic cervical internal carotid artery dissection during reperfusion therapy for intracranial cerebral artery occlusion related to atherosclerotic change.

A Survived Case of Acute Bilateral Internal Carotid Artery Occlusion Treated by Mechanical Thrombectomy

OBJECTIVE

We report a survived case of acute bilateral internal carotid artery occlusion successfully treated by mechanical thrombectomy.

CASE PRESENTATION

The patient was an 82-year-old right-handed man. Sudden consciousness disturbance and aphasia appeared, and cranial magnetic resonance angiography (MRA) revealed bilateral internal carotid artery occlusion. Cerebral angiography demonstrated occlusion between the cervical and cavernous portions of the bilateral internal carotid artery, and the growth of collateral circulation to the areas where the bilateral internal carotid artery perfused. We performed mechanical thrombectomy first on the left side, which was the main cause of his symptoms and relatively wide ischemic penumbra, and achieved recanalization of the bilateral internal carotid artery and suppressed extensive enlargement of the infarction.

CONCLUSION

Acute bilateral internal carotid artery occlusion requires an optimal treatment strategy based on the clinical symptoms and preoperative imaging.

Preprocedural Troponin T Levels Predict the Improvement in the Left Ventricular Ejection Fraction After Catheter Ablation of Atrial Fibrillation/Flutter

Background

Left ventricular (LV) systolic dysfunction is reversible in some patients once the arrhythmia is controlled. However, identifying this arrhythmia‐induced cardiomyopathy among patients with LV systolic dysfunction is challenging. We explored the factors predicting the reversibility of the LV ejection fraction (LVEF) after catheter ablation of atrial fibrillation and/or atrial flutter in patients with LV systolic dysfunction.

Methods and Results

Forty patients with a reduced LVEF (LVEF <50%; 66.2±10.7 years; 32 men) who underwent atrial fibrillation/atrial flutter ablation were included. Transthoracic echocardiography was performed before and during the early (<4 days) and late phases (>3 months) after the ablation. Responders were defined as having a normalized LVEF (≥50%) during the late phase after the ablation. The LVEF improved from 39.8±8.8 to 50.9±10.9% at 1.2±0.6 days after the procedure, and to 56.2±12.2% at 9.6±8.0 months after the procedure (both for P<0.001). Thirty (75.0%) patients were responders. The preprocedural echocardiographic parameters were comparable between the responders and nonresponders. In the multivariate analysis, the preprocedural high‐sensitivity troponin T was the only independent predictor of the recovery of the LV dysfunction during the late phase after ablation (odds ratio, 1.17; 95% CI, 1.06–1.33; P=0.001), and a level of ≤12 pg/mL predicted recovery of the LV dysfunction with a high accuracy (sensitivity, 90.0%; specificity, 76.7%; positive predictive value, 56.3%; and negative predictive value, 95.8%).

Conclusions

Preprocedural high‐sensitivity troponin T levels might be a simple and useful parameter for predicting the reversibility of the LV systolic dysfunction after atrial fibrillation/atrial flutter ablation in patients with a reduced LVEF.

An artificial impact on the asteroid (162173) Ryugu formed a crater in the gravity-dominated regime

The Hayabusa2 spacecraft investigated the small asteroid Ryugu, which has a rubble-pile structure. We describe an impact experiment on Ryugu using Hayabusa2's Small Carry-on Impactor. The impact produced an artificial crater with a diameter >10 meters, which has a semicircular shape, an elevated rim, and a central pit. Images of the impact and resulting ejecta were recorded by the Deployable CAMera 3 for >8 minutes, showing the growth of an ejecta curtain (the outer edge of the ejecta) and deposition of ejecta onto the surface. The ejecta curtain was asymmetric and heterogeneous and it never fully detached from the surface. The crater formed in the gravity-dominated regime; in other words, crater growth was limited by gravity not surface strength. We discuss implications for Ryugu's surface age.

Cryothermal atrial linear ablation in patients with atrial fibrillation: An insight from the comparison with radiofrequency atrial linear ablation

BACKGROUND

Atrial linear lesions are generally created with radiofrequency energy. We sought to evaluate the feasibility of cryothermal atrial linear ablation.

METHODS AND RESULTS

Twenty-one atrial fibrillation (AF) patients underwent linear ablation on the left atrial (LA) roof, mitral isthmus (MI), and cavotricuspid isthmus (CTI) with 8-mm-tip cryocatheters following pulmonary vein isolation. The data were compared with those of 31 patients undergoing linear ablation with irrigated-tip radiofrequency catheters. Conduction block was successfully created in 18 of 20 (90%), 9 of 21 (43%), and 20 of 20 (100%) on the LA roof, MI, and CTI by endocardial cryoablation alone with 19.0 (12.0-24.0), 30.0 (23.0-34.0), and 14.0 (14.0-16.0) minute cryo applications, respectively. The presence of either an interposed circumflex artery or pouch at the MI was significantly associated with failed MI block (P = .04). Conduction block was created in 25 of 31 (83.9%), 27 of 31 (87.1%), and 30 of 31 (96.8%) on the roof, MI, and CTI, respectively, by radiofrequency ablation. During the 17.5 (13.0-31.7) months of follow-up, freedom from AF/atrial tachycardia (AT) was significantly higher in the cryo group (P = .05); especially, recurrent AT was more frequent in the RF group (8/31 vs 1/21; P = .03). Conduction block across the roof, MI, and CTI was durable in 6 of 12 (50.0%), 4 of 12 (33.3%), and 9 of 12 (75.0%) patients during second procedures. All nine patients (except one) with recurrent ATs had at least one roof or MI conduction resumption.

CONCLUSIONS

Cryoablation is effective for creating a roof and CTI linear block, however, creating MI block by endocardial ablation alone was often challenging. Conduction resumption of LA linear block is common and recurrent arrhythmias, especially iatrogenic ATs, are more frequently observed after radiofrequency linear ablation.

Sequential organ failure assessment score on admission predicts long-term mortality in acute heart failure patients

Aims

The sequential organ failure assessment (SOFA) score has been a widely used predictor of outcomes in the intensive care unit, whereas short‐term and long‐term survivals of heart failure (HF) patients are predicted by the American Heart Association Get With the Guidelines–Heart Failure (GWTG‐HF) risk score. The purpose of present study was to examine whether the SOFA score on admission is more useful for predicting long‐term mortality in acute HF patients than the GWTG‐HF risk score.

Methods and results

A total of 269 patients (mean age, 78.5 ± 10.9 years; all‐cause mortality, 53.9%) seen in a single facility from January 2007 to December 2016 were enrolled retrospectively. They were followed up for a mean of 32.1 ± 22.3 months. All‐cause death was associated with higher SOFA and GWTG‐HF risk scores. However, no significant difference was observed in the area under the curve value between the scores. Kaplan–Meier survival analysis indicated that higher SOFA scores (P < 0.001) and GWTG‐HF risk scores (P < 0.001) were related to increased probabilities of all‐cause death. On multivariate Cox proportional hazard model analysis, the SOFA score (P < 0.001) and GWTG‐HF (P < 0.001) score were independent predictors of all‐cause death. Incorporating the SOFA score into the GWTG‐HF risk score yielded a significant net reclassification improvement and integrated discrimination improvement. On decision curve analysis, the net benefit of the SOFA score model when compared with the reference model was greater across the range of threshold probabilities.

Conclusions

In acute HF patients, long‐term all‐cause mortality can be predicted by the SOFA score. Discriminative performance metrics, such as net reclassification improvement, integrated discrimination improvement, and decision curve analysis, for predicting mortality were improved when the SOFA score was incorporated.

Dissection of the Vertebral Artery Fenestration Limb Presenting with Occlusion After Rupture

BACKGROUND

Dissection of a vertebral artery (VA) fenestration is extremely rare. We herein present the first case of a patient who presented with the dissection of a VA fenestration limb accompanied by occlusion after rupture, who was treated with internal trapping of the dissected limb and the parent artery proximal to the fenestration.

CASE DESCRIPTION

A 55-year-old man presented with sudden headache and altered consciousness. Computed tomography at admission showed subarachnoid hemorrhage. Angiography showed occlusion of the inner limb of the vertebrobasilar junction fenestration, and the occluded ends had a tapered shape, suggesting the occlusion of the dissection of the inner limb after rupture. Angiography immediately before embolization revealed inner limb recanalization with an irregular string sign; thus only the inner limb was embolized. Angiography after embolization showed near-complete suppression of the blood flow in the inner limb; however, a slight antegrade flow through the coil mass was observed in the late phase. The procedure was finished with the expectation of complete occlusion over time with natural heparin reversal. Angiography 8 days after embolization revealed a significant increase in antegrade blood flow through the coil mass within the inner limb. Therefore additional embolization of the parent artery proximal to the fenestration was performed, which achieved complete occlusion.

CONCLUSIONS

The embolization length was limited and the antegrade blood flow through the other limb remained during internal trapping for the dissected VA fenestration limb; therefore careful observation of the blood flow to the dissected segment after embolization is necessary.

A genome-wide DNA methylation signature for SETD1B-related syndrome

SETD1B is a component of a histone methyltransferase complex that specifically methylates Lys-4 of histone H3 (H3K4) and is responsible for the epigenetic control of chromatin structure and gene expression. De novo microdeletions encompassing this gene as well as de novo missense mutations were previously linked to syndromic intellectual disability (ID). Here, we identify a specific hypermethylation signature associated with loss of function mutations in the SETD1B gene which may be used as an epigenetic marker supporting the diagnosis of syndromic SETD1B-related diseases. We demonstrate the clinical utility of this unique epi-signature by reclassifying previously identified SETD1B VUS (variant of uncertain significance) in two patients.

Biodegradable Flow Diverter for the Treatment of Intracranial Aneurysms: A Pilot Study Using a Rabbit Aneurysm Model

Background

Herein, we report an in vivo study of a biodegradable flow diverter (BDFD) for aneurysm occlusion. Conceptually, BDFDs induce a temporal flow‐diverting effect and provide a vascular scaffold for neointimal formation at the neck of the aneurysm until occlusion. This offers several potential advantages, including a reduced risk of remote ischemic complications and more treatment options in case of device failure to occlude the aneurysm.

Methods and Results

A BDFD consisting of 48 poly‐l‐lactic acid wires with radiopaque markers at both ends was prepared. An in vitro degradation test of the BDFD was performed. Thirty‐six BDFDs were implanted in a rabbit aneurysm model. Digital angiography, optical coherence tomography, histopathology, and scanning electron microscopy were performed after 1, 3, and 6 months, and 1 year. The in vitro degradation test showed that the BDFD was almost degraded in 1.5 years. In the in vivo experiment, aneurysm occlusion rates were 0% at 1 month, 20% at 3 months, 50% at 6 months, and 33% at 1 year. Optical coherence tomography showed that luminal area stenosis was the highest at 3 months (16%) and decreased afterward. Immunohistochemical analysis showed that more than half of the luminal surface area was covered by endothelial cells at 1 month. Device fragmentation was not observed in any lesions.

Conclusions

This first in vivo study of a BDFD shows the feasibility of using BDFDs for treating aneurysms; however, a longer follow‐up is required for comprehensive evaluation of the biological and mechanical behavior peculiar to biodegradable devices.

Effects of Sitagliptin on the Coronary Flow Reserve, Circulating Endothelial Progenitor Cells and Stromal Cell-derived Factor-1alpha

Objective Circulating endothelial progenitor cells (EPCs) are regulated by stromal cell-derived factor-1alpha (SDF-1α) and are reduced in type 2 diabetes mellitus (DM). SDF-1α is a substrate of dipeptidyl-peptidase-4 (DPP-4), so we investigated whether or not DPP-4-inhibitors modulate EPC levels in type 2 DM patients with coronary artery disease (CAD). Methods Thirty patients with CAD and type 2 DM treated using an ordinary regimen were enrolled. EPC and SDF-1α levels were compared between those receiving additional 24-week treatment with a DPP-4-inhibitor (n=11) and no additional treatment (n=19). We determined the HbA1c, 1.5-Anhydro-D-glucitol (1,5-AG), coronary flow reserve (CFR), brain natriuretic peptide (BNP), E/e', and circulating EPC proportion and SDF-1α levels at baseline and the end of follow-up. The CFR was assessed using a dual-sensor-equipped guidewire. The primary endpoints were changes in the EPC count, SDF-1α levels, and CFR from baseline to the end of follow-up. The secondary endpoints were changes in the HbA1c and 1,5-AG, which are useful clinical markers of postprandial hyperglycemia, as well as the BNP and E/e'. Results After the 6-month follow-up, compared with ordinary regimen subjects, the patients receiving a DPP-4-inhibitor showed no significant increase in the EPC proportion (-0.01±0.50 vs. 0.02±0.77%, p=0.87), SDF-1α level (-600.4±653.6 vs. -283.2±543.1 pg/mL, p=0.18), or CFR (0.0±0.2 vs. 0.1±0.6, p=0.20), whereas both the 1.5-AG level (2.4±4.6 vs. -0.7±2.5 μg/dL, p=0.07) and HbA1c (-0.8±1.8 vs. 0.0±0.7%, p=0.02) were improved. There were no significant differences between the two groups in changes in the BNP and E/e'. Conclusion DPP-4 inhibition with sitagliptin did not increase or decrease the EPC proportion, SDF-1α level, or CFR, although the glycemic control was improved.

P6339Sequential organ failure assessment score on admission predicts long-time mortality of the patients with acute heart failure

Background

Despite the remarkable advances in the treatment options of acute heart failure (HF), prognosis assessment remains an ongoing challenge. Previous studies revealed only a moderate accuracy of models predicting mortality. Sequential Organ Failure Assessment (SOFA) Score are widely used in the intensive care unit (ICU) to predict outcome and predicted higher long-time mortality in unselected patients in cardiac ICU. In addition, the American Heart Association Get With the Guidelines–Heart Failure (GWTG-HF) risk score allows for risk stratification of 30-day outcome for patients hospitalized with HF. The purpose of this study was to evaluate whether SOFA score on admission is useful for long-time mortality prediction in acute HF patients and also to assess the discriminative performance as compared with GWTG-HF risk score.

Methods

This was a single-centre, retrospective cohort study. Between January 2007 and December 2016, we screened eligible 661 consecutive patients with acute HF administered at our hospital. SOFA score on admission of 294 patients was able to calculate retrospectively. We enrolled 269 patients who could complete follow up evaluation for more than 1 year. Endpoint was all-cause mortality after admission. Additive information of SOFA score was evaluated by area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA).

Results

The 269 patients were included in this study (78.5±10.9 years; 136 men; left ventricular ejection fraction [EF], 49.8±16.6%) during a mean follow-up of 32.1±22.3 months. Patients with all-cause death had higher SOFA score (4.2±2.3 versus 2.8±1.8, p<0.001; AUC, 0.689) and GWTG-HF risk score (44.0±7.6 versus 38.1±7.9, P<0.001, AUC, 0.692).

Kaplan-Meier survival analysis demonstrated higher SOFA scores (P<0.001) and GWTG-HF risk scores (P<0.001) appears to be related to increase probabilities of all cause death. A multivariate Cox proportional hazard model were made with adjustment for SOFA score, GWTG-HF risk score, age, gender and ejection fraction. As a result, SOFA score (hazard ratio [HR] 1.227; 95% confidence interval [CI], 1.130 to 1.326; P<0.001), GWTG-HF (HR, 1.054; 95% CI, 1.029 to 1.078; P<0.001) and age (HR, 1.069; 95% CI 1.048 to 1.092; P<0.001) were independent predictors of all cause death and HR of SOFA score was the highest in these parameters. Incorporating SOFA score into GWTG-HF score yielded a significant NRI (0.528 (95% CI 0.291 to 0.765) and IDI (0.046 (95% CI 0.020 to 0.072). In DCA, compared with the reference model, the net benefit for SOFA score model was greater across the range of threshold probabilities.

Conclusions

The SOFA score, simple and validated mortality risk score can predict long-term all-cause mortality in patients with acute HF. Discriminative performance metrics such as NRI, IDI and DCA were improved on incorporation of the SOFA score for prediction of mortality.

Resolvin E3 attenuates allergic airway inflammation via the interleukin-23-interleukin-17A pathway

We investigated the effects of resolvin E (RvE) 1, RvE2, and RvE3 on IL-4- and IL-33-stimulated bone marrow-derived dendritic cells (BMDCs) from house dust mite (HDM)-sensitized mice. We also investigated the role of RvE3 in a murine model of HDM-induced airway inflammation. In vitro, BMDCs from HDM-sensitized mice were stimulated with IL-4 and IL-33 and then treated with RvE1, RvE2, RvE3, or vehicle. RvE1, RvE2, and RvE3 suppressed IL-23 release from BMDCs. In vivo, RvE3 administrated to HDM-sensitized and challenged mice in the resolution phase promoted a decline in total numbers of inflammatory cells and eosinophils, reduced levels of IL-23 and IL-17 in lavage fluid, and suppressed IL-23 and IL-17A mRNA expression in lung and peribronchial lymph nodes. RvE3 also reduced resistance in the lungs of HDM-sensitized mice. A NanoBiT β-arrestin recruitment assay using human embryonic kidney 293 cells revealed that pretreatment with RvE3 suppressed the leukotriene B4 (LTB4)-induced β-arrestin 2 binding to LTB4 receptor 1 (BLT1R), indicating that RvE3 antagonistically interacts with BLT1R. Collectively, these findings indicate that RvE3 facilitates the resolution of allergic airway inflammation, partly by regulating BLT1R activity and selective cytokine release by dendritic cells. Our results accordingly identify RvE3 as a potential therapeutic target for the management of asthma.-Sato, M., Aoki-Saito, H., Fukuda, H., Ikeda, H., Koga, Y., Yatomi, M., Tsurumaki, H., Maeno, T., Saito, T., Nakakura, T., Mori, T., Yanagawa, M., Abe, M., Sako, Y., Dobashi, K., Ishizuka, T., Yamada, M., Shuto, S., Hisada, T. Resolvin E3 attenuates allergic airway inflammation via the interleukin-23-interleukin-17A pathway.

Pressure-guided second-generation cryoballoon pulmonary vein isolation: Prospective comparison of the procedural and clinical outcomes with the conventional strategy

BACKGROUND

The utility of pressure waveform analyses to assess pulmonary vein (PV) occlusions has been reported in cryoballoon PV isolation (CB-PVI) using first-generation CBs. This prospective randomized study compared the procedural and clinical outcomes of pressure-guided and conventional CB-PVI.

METHODS AND RESULTS

Sixty patients with paroxysmal atrial fibrillation underwent CB-PVI with 28-mm second-generation CBs. PV occlusions were assessed either by real-time pressure waveforms without contrast utilization (pressure-guided group) or contrast injections (conventional group) and randomly assigned. Before the randomization, 24 patients underwent pressure-guided CB-PVIs. In the derivation study, a vein occlusion was obtained in 88/96 (91.7%) PVs among which 86 (97.7%) were successfully isolated by the application. In the validation study, the nadir balloon temperature and total freezing time did not significantly differ per PV between the two groups. The positive predictive value of the vein occlusion for predicting successful acute isolations was similar (93 of 103 [90.2%] and 89 of 98 [90.8%] PVs; P = 1.000), but the negative predictive value was significantly higher in pressure-guided than angiographical occlusions (14 of 17 [82.3%] vs 7 of 22 [31.8%]; P = .003). Both the procedure (57.7 ± 14.2 vs 62.6 ± 15.8 minutes; P = .526) and fluoroscopic times (16.3 ± 6.4 vs 20.1 ± 6.1; P = .732) were similar between the two groups, however, the fluoroscopy dose (130.6 ± 97.7 vs 353.2 ± 231.4 mGy; P < .001) and contrast volume used (0 vs 17.5 ± 7.7 mL; P < .001) were significantly smaller in the pressure-guided than conventional group. During 27.8 (5-39) months of follow-up, the single procedure arrhythmia freedom was similar between the two groups (P = .438).

CONCLUSIONS

Pressure-guided second-generation CB-PVIs were similarly effective and as safe as conventional CB-PVIs. This technique required no contrast utilization and significantly reduced radiation exposure more than conventional CB-PVIs.

Efficacy and Safety of Tolvaptan in Patients More Than 90 Years Old With Acute Heart Failure

BACKGROUND

The oral vasopressin-2 receptor antagonist, tolvaptan, causes aquaresis and improves symptoms in patients with congestive heart failure. However, few studies have explored the effect of tolvaptan in acute heart failure (AHF) patients ≥90 years old.

METHODS

This study enrolled 106 AHF patients treated with tolvaptan added to standard therapy. The subjects were divided into 2 groups: ≥90-year-old patients (over-90 group, mean 92 ± 2 years, n = 45) and <90-year-old patients (under-90 group, mean 76 ± 11 years, n = 61). Patients' characteristics were assessed, and efficacy and safety were compared between the 2 groups.

RESULTS

The over-90 group had a lower proportion of male patients, lower body weight, and higher ejection fraction. The under-90 group had significantly higher prevalence of ischemic heart disease and diabetes mellitus. There were no significant differences between the 2 groups in total urine volume at 24 and 48 hours (1934 ± 983 mL vs 1816 ± 1028 mL, P = 0.58 and 3806 ± 1444 mL vs 4078 ± 1851 mL, P=0.47, respectively), the mean change in body weight (-3.0 ± 2.7 kg vs -2.6 ± 2.6 kg, P = 0.50), improvement of congestive symptoms, changes in serum sodium and creatinine levels, the incidences of hypernatremia (n = 0, 0% vs n = 1, 1.6%, P = 0.63), and worsening renal function (n = 9, 20% vs n = 17, 28%, P = 0.48).

CONCLUSION

The efficacy and safety of tolvaptan in AHF patients aged more than 90 years were comparable to those of <90 years old. Tolvaptan provides a complementary therapeutic option for AHF patients aged more than 90 years.

Precision Analysis of the ^{136}Xe Two-Neutrino ββ Spectrum in KamLAND-Zen and Its Impact on the Quenching of Nuclear Matrix Elements

We present a precision analysis of the ^{136}Xe two-neutrino ββ electron spectrum above 0.8 MeV, based on high-statistics data obtained with the KamLAND-Zen experiment. An improved formalism for the two-neutrino ββ rate allows us to measure the ratio of the leading and subleading 2νββ nuclear matrix elements (NMEs), ξ_{31}^{2ν}=-0.26_{-0.25}^{+0.31}. Theoretical predictions from the nuclear shell model and the majority of the quasiparticle random-phase approximation (QRPA) calculations are consistent with the experimental limit. However, part of the ξ_{31}^{2ν} range allowed by the QRPA is excluded by the present measurement at the 90% confidence level. Our analysis reveals that predicted ξ_{31}^{2ν} values are sensitive to the quenching of NMEs and the competing contributions from low- and high-energy states in the intermediate nucleus. Because these aspects are also at play in neutrinoless ββ decay, ξ_{31}^{2ν} provides new insights toward reliable neutrinoless ββ NMEs.