Verification of the seizure liability of compounds based on their in vitro functional activity in cultured rat cortical neurons and co-cultured human iPSC-derived neurons with astrocytes and in vivo extrapolation to cerebrospinal fluid concentration

Methodical screening of safe and efficient drug candidate compounds is crucial for drug development. A high-throughput and accurate compound evaluation method targeting the central nervous system can be developed using in vitro neural networks. In particular, an evaluation system based on a human-derived neural network that can act as an alternative to animal experiments is desirable to avoid interspecific differences. A microelectrode array (MEA) is one such evaluation system, and can measure in vitro neural activity; however, studies on compound evaluation criteria and in vitro to in vivo extrapolation are scarce. In this study, we identified the parameters that can eliminate the effects of solvents from neural activity data obtained using MEA allow for accurate compound evaluation. Additionally, we resolved the issue associated with compound evaluation criteria during MEA using principal component analysis by considering the neuronal activity exceeding standard deviation (SD) of the solvent as indicator of seizurogenic potential. Overall, 10 seizurogenic compounds and three negative controls were assessed using MEA-based co-cultured human-induced pluripotent stem cell-derived neurons and astrocytes, and primary rat cortical neurons. In addition, we determined rat cerebrospinal fluid (CSF) concentrations during tremor and convulsion in response to exposure to test compounds. To characterize the in vitro to in vivo extrapolation and species differences, we compared the concentrations at which neuronal activity exceeding the SD range of the solvent was detectable using the MEA system and rat CSF concentration.

Slowly Progressive Bone Marrow Metastasis of Gastric Cancer Followed-up Without Treatment

BACKGROUND/AIM

Bone marrow metastasis (BMM) of gastric cancer (GC) is complicated by disseminated intravascular coagulation syndrome (DIC), which is more prominent in poorly differentiated carcinoma. This is one of the first case reports of a slowly progressing BMM of GC after approximately 1 year of follow-up without treatment.

CASE REPORT

A 72-year-old woman underwent total gastrectomy and splenectomy for GC in February 2012. The pathological diagnosis was that of a moderately differentiated adenocarcinoma. Five years later in December 2017, she developed anemia; however, its cause remained unknown. Due to worsening of the anemia, the patient visited the Kakogawa Central City Hospital in October 2018. Bone marrow biopsy revealed an infiltration of caudal type homeobox 2-positive cancer cells, and our diagnosis was BMM of GC. There was no DIC. The incidence of BMM is high in well- or moderately differentiated breast cancer but rarely causes DIC.

CONCLUSION

As with breast cancer, in moderately differentiated cancer cells, BMM of GC may progress slowly after the appearance of symptoms without causing DIC.

Late-onset doxorubicin-induced congestive heart failure in an elderly cancer survivor: A case report

Background

Recently, the survival rate of patients with cancer has improved annually due to advancements in cancer diagnosis and treatment technologies. Meanwhile, late-onset complications associated with cancer treatment significantly affect survival and quality of life. However, different from pediatric cancer survivors, there is no unified view on the follow-up of late complications in elderly cancer survivors. We reported a case of congestive heart failure as a late-onset complication of doxorubicin (DXR) in an elderly cancer survivor.

Case report

The patient is an 80-year-old woman with hypertension and chronic renal failure. She received six cycles of chemotherapy for Hodgkin's lymphoma that started in January 201X-2. The total dose of DXR was 300 mg/m2, and a transthoracic echocardiogram (TTE) performed in October 201X-2, showed good left ventricular wall motion (LVWM). In April 201X, she suddenly developed dyspnea. Upon arrival at the hospital, a physical examination revealed orthopnea, tachycardia, and leg edema. A chest radiograph showed cardiac enlargement and pleural effusion. A TTE showed diffusely reduced LVWM and a left ventricular ejection fraction in the 20% range. After close examination, the patient was diagnosed with congestive heart failure due to late-onset DXR-induced cardiomyopathy.

Conclusion

Late-onset DXR-induced cardiotoxicity is considered high-risk from 250 mg/m2 or higher. Elderly cancer survivors are at higher risk of cardiotoxicity than non-elderly cancer survivors and may require closer follow-up.

Is CT or FDG-PET more useful for evaluation of the treatment response in metastatic HER2-positive breast cancer? a case report and literature review

Response evaluation criteria in solid tumors version 1.1 (RECIST ver1.1) has been widely adopted to evaluate treatment efficacy in solid tumors, including breast cancer (BC), in clinical trials and clinical practice. RECIST is based mainly on computed tomography (CT) images, and the role of fluorodeoxyglucose-positron emission tomography (FDG-PET) is limited. However, because the rate of tumor shrinkage on CT does not necessarily reflect the potential remaining tumor cells, there may be a discrepancy between the treatment response and prognosis in some cases. Here we report a case of metastatic human epidermal growth factor receptor 2 (HER2)-positive BC where FDG-PET was preferable to CT for evaluation of the treatment response. A 40-year-old woman became aware of a lump in her right breast in September 201X. She was pregnant and underwent further examinations, including a biopsy, in November. The diagnosis was HER2-positive BC (cT2N2bM1, stage IV). Trastuzumab plus pertuzumab plus docetaxel (TPD) therapy was initiated in December 201X. CT performed in February 201X+1 showed cystic changes in the metastatic lesions in the liver, and the treatment response was stable disease (SD) according to RECIST. However, FDG-PET in March 201X+1 did not detect abnormal uptake of FDG in the hepatic lesions. The disease remained stable thereafter. Thus, tumor shrinkage may not be apparent in situations where the response to treatment results in rapid changes in blood flow within the tumor, which is associated with cystic changes. When patients with hypervascular liver metastases receive treatment with highly effective regimens, the target lesion may show cystic changes rather than shrinkage, as observed in the present case. Therefore, FDG-PET is sometimes superior to CT in judging a tumor response.

Delayed diagnosis of bladder cancer in a patient with autosomal dominant polycystic kidney disease

ABSTRACT

Approximately 50% of autosomal dominant polycystic kidney disease (ADPKD) patients have gross hematuria, but few cases of bladder cancer complications are known. We report a case of a 49-year-old female ADPKD patient with bladder cancer, who was presented to our hospital 4 months after the onset of gross hematuria. A computed tomography (CT) scan showed a bladder mass, enlarged pelvic and left inguinal lymph nodes, multiple liver cysts, and a polycystic kidney. Based on family history, CT scan results, and lymph node biopsy, we diagnosed the patient with uroplakin III-negative bladder cancer with squamous metaplasia and ADPKD. The patient was treated with systemic chemotherapy but died 2 months after the definitive diagnosis. The delayed diagnosis was disastrous, and malignancy should be considered in the differential diagnosis when symptoms suggestive of malignancy such as hematuria appear. Particularly, uroplakin III-negative advanced bladder cancer has a poor prognosis and requires early diagnosis and treatment.

Case report: Paratesticular dedifferentiated liposarcoma with poor prognosis

BACKGROUND/AIM

Most paratesticular liposarcomas (PLPSs) are well-differentiated liposarcomas (WDLPSs) with favourable prognoses. As such, the rare occurrence of PLPS often leads to its misdiagnosis as a hernia or hydrocele on physical examination. Curative resection of the tumour may not be possible in cases where PLPSs have transformed into dedifferentiated liposarcomas (DDLPSs) owing to a delay in diagnosis. Herein, we describe a case of unresectable paratesticular dedifferentiated liposarcoma (PDDLPS) with poor prognosis due to delayed diagnosis.

CASE REPORT

A 57-year-old man visited our hospital with a chief complaint of a right scrotal mass, which was diagnosed as scrotal hydrocele but without treatment or follow-up. Eight years later, the patient complained of abdominal distension, and a computed tomography scan revealed the presence of retroperitoneal and right scrotal masses. The right scrotal mass was removed, and histopathology revealed DDLPS. The patient was diagnosed with unresectable PDDLPS metastasising to the retroperitoneum, and the left pleura was treated with doxorubicin. After an initial response, pleural effusion and ascites increased during the sixth cycle of chemotherapy. The patient subsequently received eribulin but died 5 months after the initial DDLPS diagnosis.

CONCLUSION

It is difficult to distinguish PLPS from benign inguinal hernia and hydrocele testis on physical examination. PLPS generally has a considerably good prognosis. However, failure to diagnose WDLPS can be dangerous as it might lead to malignant transformation to DDLPS, which has a poor prognosis. Physicians should consider this malignancy when examining patients with hernias or hydroceles of the inguinal region and should perform ultrasonography or magnetic resonance imaging.

Extensive ablation strategy for persistent atrial fibrillation impairs left atrial function but reduces recurrence rate

Background

In catheter ablation for persistent atrial fibrillation (AF), extensive ablation strategy, such as linear ablation and/or complex fractionated atrial electrogram (CFAE) ablation in addition to pulmonary vein isolation (PVI-plus), might impair left atrial function more severely than PVI-alone strategy.

Purpose

The aim of this study is to investigate the impact of extensive ablation strategy on LA function and assess the relationship between post-ablation LA function and recurrence.

Methods

This study is a post-hoc subanalysis of the EARNEST-PVI randomized controlled trial, which investigated the efficacy of the PVI-alone strategy in comparison with PVI-plus strategy for persistent AF. From the 497 participants of EARNEST-PVI trial, we enrolled 191 patients with full datasets of pre- and post-ablation cardiac computed tomography (CT) at our Hospital. Patients were divided into PVI-alone and PVI-plus groups. Within one month before and 3 months after ablation, LA volume index (LAVI) and LA emptying fraction (LAEF) were calculated by using the Comprehensive Cardiac Analysis software on the Extended Brilliance Workspace. We assessed i) post-ablation LA function, ii) AF/atrial tachycardia (AT) -free rate after single and final session, and iii) relationship between post-ablation LAEF and ablation success in each group.

Results

The indices of baseline LA remodeling were not different between PVI-alone (N=96) and PVI-plus groups (N=95) [LAVI: 71.4 (57.8, 82.0) vs. 68.7 (61.0, 78.1), P=0.92, LAEF: 13.7 (10.0, 17.4) vs. 13.0 (10.0, 16.9), PVI-alone vs. PVI-plus, P=0.78]. In overall patients, post-ablation LAEF did not differ among them [34.4 (26.1, 40.7) vs. 31.6 (26.0, 37.4), P=0.13]. In the analysis of patients showing sinus rhythm during the CT study, LAEF was significantly higher in PVI-alone (N=87) than in PVI-plus group (N=93) [35.7 (29.0, 41.0) vs. 31.7 (26.1, 37.5), P=0.011] (Figure 1A). AF/AT-free survival rate during median follow-up of 44 months was not different after first session (63.5% vs. 68.4%, P=0.33), while PVI-plus had a tendency towards higher success rate after final session (72.9% vs. 84.2%, P=0.053) (Figure 2). In receiver operating characteristics analysis for recurrence after first session, post-ablation decreased LAEF had significantly related to recurrence after PVI-alone (AUC: 0.733, P<0.0001), but not after PVI-plus (AUC: 0.567, P=0.31) (Figure 1B, C).

Conclusion

Compared with PVI-alone strategy, PVI-plus strategy damaged LA function more severely, but tended to be related to higher success rate. Post-ablation LA function was related to recurrence in PVI-alone, but not in PVI-plus. Extensive ablation might have additional anti-arrhythmic effect regardless of iatrogenic myocardial damage. Myocardial injury by extensive ablation may less attribute to recurrence than intrinsic damage of LA.

Funding Acknowledgement

Type of funding sources: None.

Development of the new risk score to predict occurrence of atrial fibrillation early after acute myocardial infarction

Background/Introduction

New onset of atrial fibrillation (AF) is associated with adverse short- and long-term outcomes after acute myocardial infarction (AMI), and its prediction is relevant for the risk stratification in patients with AMI. Although several risk scores were developed for AF in the general population, there is no established risk score for AF occurrence after AMI.

Purpose

To develop a risk score to predict occurrence of AF early after AMI.

Methods

We enrolled consecutive 751 patients with AMI who admitted to our hospital between April 2006 and September 2012 for the present study. New occurrence of AF was defined as AF detected during hospital stay in a patient showing normal regular sinus rhythm at admission. Parameters relevant to the occurrence of AF was selected from the clinical characteristics, physical status and blood test data at admission, and peak CK/CK-MB, by stepwise logistic regression analysis. We constructed a risk score model to predict the new occurrence of AF, using selected parameters and their logistic regression coefficients. C-statistics was determined by constructing a receiver operating characteristic curve to evaluate the accuracy of the risk score for prediction of AF occurrence.

Results

We excluded 48 patients (6.4%) who had AF at admission, and 208 patients without sufficient data at admission, and thus, the study group consisted of 459 patients (age; 65±13 years, male gender; 79.6%). New AF occurrence was observed in 72 patients (14.5%). The following 7 parameters was selected as parameters related with AF (as p<0.1); Inferior/posterior AMI, use of β blockers, use of diuretics, single vessel disease, absence of reperfusion therapy, systolic blood pressure (sBP) at admission, and smoking. One point was given to sBP>128mmHg, 2 points to absence of reperfusion, and one point to other parameters. Sum of these points was calculated as the AF risk score (Table 1). AF occurred in 27.1% of patients with ≥5 points whereas it was observed 5.2% of those with <5 points. C-statistics of the risk score was 0.75 (95% CI 0.68–0.83).

Conclusion

We developed a novel risk score to estimate the risk of AF occurrence early after AMI, which can be a useful tool for the risk stratification after AMI.

Funding Acknowledgement

Type of funding sources: None.

Untreated sleep apnea and left atrial dilatation in patients with atrial fibrillation prior to catheter ablation

Background

Sleep apnea and left atrial dilatation are both risk factors for an arrhythmia recurrence after catheter ablation (CA) of atrial fibrillation (AF). Negative intrathoracic pressure fluctuations during an obstructive apnea episode may cause the left atrium to distend and stretch its wall. Whether sleep apnea is associated with left atrial dilatation in patients receiving CA of AF remains unknown.

Purpose

We sought to elucidate whether moderate or severe untreated sleep apnea was associated with left atrial dilatation in patients with AF before CA.

Methods

This study was conducted under a retrospective, single-center, observational design. The data were derived from screening tests for sleep apnea, which were routinely performed in patients scheduled to receive CA of AF in our institution. After excluding patients who were already diagnosed with sleep apnea, we enrolled 1265 consecutive patients (age 65±11 years, 27.8% females, and 46.2% of non-paroxysmal AF) who underwent both home sleep apnea testing and multidetector computed tomography (MDCT) before the CA of AF. The severity of the sleep apnea was evaluated by the apnea-hypopnea index (AHI) using a watch-type peripheral arterial tonometry. Left atrial dilatation was evaluated by the left atrial maximum volume (LA max V) using 256-slice MDCT.

Results

The age was 65±11 years, 27.8% were females, and 46.2% had non-paroxysmal AF. The mean AHI was 20.3±15.3 and LA max V 105±34 ml (R2=0.075, p<0.0001). LA dilatation was defined by larger than mean LA max V (LA max V≥105 ml). We examined an LA max V≥105 ml as a predictor. After an adjustment by an advanced age (≥65 years), non-paroxysmal AF, male sex, obesity, hypertension, and congestive heart failure, all of which were significant predictors of an LA max V≥105ml in the univariate analysis, moderate or severe sleep apnea (AHI≥15) was a significant predictor of an LA max V≥105 ml (odds ratio 1.63, 95% confidence interval 1.24–2.14, p=0.0005).

Conclusion

Among the patients scheduled to receive catheter ablation of AF, moderate or severe sleep apnea was independently associated with left atrial dilatation.

Funding Acknowledgement

Type of funding sources: None.

Sex differences in terms of recurrent atrial fibrillation after catheter ablation according to the history of heart failure: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry

Background

There are significant differences in the prevalence and prognosis of cardiovascular diseases between male and female. We previously reported that catheter ablation (CA) of atrial fibrillation (AF) was less effective in female than male, but whether their history of heart failure influence the recurrence after CA of AF remains still unknown.

Purpose

We sought to clarify sex differences in terms of AF recurrence after RFCA of AF according to the history of heart failure.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

Fourteen % of female had a history of heart failure prior to CA, while 12.8% of male had a history of heart failure at baseline (p=0.29). The 3-year cumulative incidence of AF recurrence after a single procedure was 43.3% in female and 39.0% in male (log rank P=0.0046). In patients with the history of heart failure, AF recurrence rates were 42.2% in female and 45.8% in male (log rank P=0.51). On the other hand, in patients without history of heart failure, more females experienced AF recurrence (female vs. male, 43.5% vs. 38.0%, log rank P=0.001).

The rate of AF recurrence after multiple procedures was higher in female (24.2% vs. 19.6%, log rank P<0.0001). AF recurrence rates were similar between sexes in patients with history of heart failure (female vs. male, 26.0% vs. 26.7%, log rank P=0.86), while AF recurrence rates were higher in female without history of heart failure than those in male (females vs. males, 23.9% vs. 18.5%, log rank P<0.0001).

Conclusion

The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the AF recurrence after CA of AF. Females had higher recurrence rates compared with males in patients without history of heart failure, while recurrence rates were similar between sexes in patients with history of heart failure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.

Difficulty in Distinguishing Pulmonary Arterial Intimal Sarcoma from Pulmonary Thromboembolism Using FDG PET/CT

BACKGROUND/AIM

Pulmonary arterial intimal sarcoma (PAIS) is a rare malignant soft tissue tumor that is difficult to differentiate from pulmonary thromboembolism (PTE). Therefore, pre-operative diagnosis is often difficult. However, recent advances in fluorodeoxyglucose positron emission tomography (FDG-PET) have enabled the use of standardized uptake values (SUVs) for the differential diagnosis of PAIS from PTE, and the frequency of diagnosis of PAIS has increased. Here, we report a case of PAIS that was difficult to differentiate from PTE despite using FDG-PET.

CASE REPORT

A 40-year-old woman presented with gradually worsening exertional dyspnea. Contrast-enhanced computed tomography (CT) revealed lesions with poor enhancement in the right lateral basal pulmonary artery. FDG-PET/CT did not reveal any tumor or thrombosis in other areas. Cytological evaluation using a right ventricular catheter did not lead to a definitive diagnosis. Because the patient did not respond to anticoagulation, we performed pulmonary artery endarterectomy. Pathological examination of the pulmonary artery tumor revealed a mucinous tumor with an edematous stroma and spindle-shaped tumor-cell proliferation, which confirmed the diagnosis of PAIS. However, FDG/PET demonstrated a low SUV of 3.4.

CONCLUSION

Some PAISs with low cellular densities and high mucous tissue proportions have SUVs similar to those in PTE. In patients with low FDG uptake, if PAIS is suspected based on other objective findings, additional exploration using highly invasive tests or surgical procedures specific to PAIS is warranted.

Raster plots machine learning to predict the seizure liability of drugs and to identify drugs

In vitro microelectrode array (MEA) assessment using human induced pluripotent stem cell (iPSC)-derived neurons holds promise as a method of seizure and toxicity evaluation. However, there are still issues surrounding the analysis methods used to predict seizure and toxicity liability as well as drug mechanisms of action. In the present study, we developed an artificial intelligence (AI) capable of predicting the seizure liability of drugs and identifying drugs using deep learning based on raster plots of neural network activity. The seizure liability prediction AI had a prediction accuracy of 98.4% for the drugs used to train it, classifying them correctly based on their responses as either seizure-causing compounds or seizure-free compounds. The AI also made concentration-dependent judgments of the seizure liability of drugs that it was not trained on. In addition, the drug identification AI implemented using the leave-one-sample-out scheme could distinguish among 13 seizure-causing compounds as well as seizure-free compound responses, with a mean accuracy of 99.9 ± 0.1% for all drugs. These AI prediction models are able to identify seizure liability concentration-dependence, rank the level of seizure liability based on the seizure liability probability, and identify the mechanism of the action of compounds. This holds promise for the future of in vitro MEA assessment as a powerful, high-accuracy new seizure liability prediction method.

Association between myocardial wall thickness and left ventricular functional recovery after catheter ablation of atrial fibrillation in patients with reduced ejection fraction

Background

Catheter ablation of atrial fibrillation (AFCA) is an effective treatment to develop left ventricular (LV) functional recovery. However, the degree of recovery differs between individuals due to the different extent of myocardial fibrosis and scarring.

Purpose

To examine whether pre-ablation LV wall thickness (WT) and its regional heterogeneity predict LV functional recovery after AFCA in patients with LV systolic dysfunction.

Methods

Of 3682 consecutive patients who underwent first-time AFCA between January 2012 and September 2020 in our institution, 174 (age, 63±10 years; male, 83%; ischemic cardiomyopathy, 14%) with a baseline LV ejection fraction (LVEF) of <40% were retrospectively evaluated. They were subjected to 256-slice MDCT scanning at baseline and 3 months after AFCA. Baseline WT was evaluated by 16-segment model. Mean and standard deviation (SD) of 16 regional WT were calculated in both end-systolic and end-diastolic phase.

Results

LVEF significantly improved from 30±7% to 57±17% (p<0.001) after AFCA. Increase in LVEF (delta-LVEF) was positively correlated with baseline end-diastolic WT (r=0.31, p<0.001) and negatively correlated with SD of end-systolic WT (r=−0.21, p=0.007). Independent of WT measurements, delta-LVEF was negatively correlated with LV end-diastolic volume (r=−0.42, p<0.001). We created a scoring system to predict the degree of wall motion recovery using the median value of the 3 variables; assigned 1 point each for end-diastolic WT >7.4mm, SD of end-systolic WT <1.61mm, and LV end-diastolic volume <125ml. The model successfully predicted improvement in LVEF after AFCA (0 point (N=13) vs. 1 point (N=72) vs. 2–3 point (N=89), 11±16% vs. 20±17% vs. 33±12%, p<0.001).

Conclusion

Myocardial WT and its regional heterogeneity as well as LV end-diastolic volume predicted functional recovery after AFCA in patients with reduced LVEF.

Funding Acknowledgement

Type of funding sources: None.

Prediction of functional capacity by the HFA-PEFF score in patients with acute decompensated heart failure with preserved ejection fraction: a post-hoc analysis from the PURSUIT-HFpEF registry

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) is still challenging, and the H2FPEF- and the HFA-PEFF score were proposed as simple and reliable diagnostic tools. We recently reported that the HFA-PEFF score was significantly associated with the composite endpoint of all-cause death and heart failure readmission in patients with acute decompensated HFpEF (Sotomi. Eur J Heart Fail, in press).

Purpose

To investigate the relation whether the HFA-PEFF or H2FPEF score can evaluate functional capacity in patients with HFpEF

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for acute decompensated HFpEF. We performed 6 minute walk (6MW) test and measured NT-proBNP before discharge. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients (age 81±9 years, male gender 45%) hospitalized for acute decompensated HFpEF for the present study. The H2FPEF score was obtained in 588 (77.7%) patients and all patients had ≥2 points. The HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. We divided these patients into 3 groups based on the HFA-PEFF score (score 2 to 4, 5, and 6) or on the H2FPEF score (score 0 to 3, 4 to 5 and 6 to 8). There were a significant difference in NT-pro BNP between 3 groups based on HFA-PEFF score (p=0.01, Table 1), and patients with score 6 had significantly higher NT-proBNP than those with score 2 to 4 (p=0.02). A significant difference was observed in 6MW distance among these groups (p=0.04, Table), and those with score 6 had significantly shorter distance than those with score 2 to 4 (p=0.04). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE, and Kaplan-Meier survival analysis demonstrated that classification of HFA-PEFF score significantly stratified the patients' risk for MACE. On the other hand, there was no significant difference in 6MW distance among 3 groups based on H2FPEF score (p=0.53), and H2FPEF score was not an independent predictor for MCE by the Cox model analysis. Moreover, the lowest H2PEF score group had higher NT-proBNP than other 2 groups (p=0.02)

Conclusions

The HFA-PEFF score predicted functional capacity as well as prognosis in patients hospitalized for HFpEF, while the H2PEF score did not.

Funding Acknowledgement

Type of funding sources: None. Table 1

Principal Component Analysis to Distinguish Seizure Liability of Drugs in Human iPS Cell-Derived Neurons

Screening for drug discovery targeting the central nervous system requires the establishment of efficient and highly accurate toxicity test methods that can reduce costs and time while maintaining high throughput using the function of an in vitro neural network. In particular, an evaluation system using a human-derived neural network is desirable in terms of species difference. Despite the attention the microelectrode array (MEA) is attracting among the evaluation systems that can measure in vitro neural activity, an effective analysis method for evaluation of toxicity and mechanism of action has not yet been established. Here we established analytical parameters and multivariate analysis method capable of detecting seizure liability of drugs using MEA measurement of human iPS cell-derived neurons. Using the spike time series data of all drugs, we established periodicity as a new analytical parameter. Periodicity has facilitated the detection of responses to seizurogenic drugs, previously difficult to detect with conventional analytical parameters. By constructing a multivariate analytical method that identifies a parameter set that achieves an arbitrary condition, we found that the parameter set comprising total spikes, maximum frequency, inter maximum frequency interval, coefficient of variance of inter maximum frequency interval, and periodicity can uniformly detect the seizure liability of seizurogenic drugs with different mechanisms of action. Seizurogenic drugs were suggested to increase the regularity of the network burst in MEA measurements in human iPS cell-derived neurons.

The utility of a novel approach to quantify dyssynchrony by multidetector computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background

Quantification of left ventricular (LV) dyssynchrony is of great interest for resynchronization therapy (CRT). Recently, cardiac computed tomography (CCT) is feasible for evaluation of dyssynchrony. Our aim was to assess a novel simplified approach using CCT to quantify LV dyssynchrony.

Methods

We studied 346 consecutive patients with a wide range of QRS width and ejection fractions (EF). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT (Brilliance 256 iCT, Philips Medical Systems) was performed before CRT. After CCT scan, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and a time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software "Myocardial Contraction Map" (Argus, Inc Ehime, Japan). The standard deviation of all segments modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT.

Results

%SD was feasible in all patients, respectably. %SD was significantly different between the different QRS duration groups; narrow QRS (<120ms): 9 ± 5%, relatively wide QRS (120-150 ms): 11 ± 6%, and significantly wide QRS (>150 ms): 14 ± 7% (p <0.001). Moreover, there was significantly difference in %SD between the different morphology groups; normal: 9 ± 7%, Non-left bundle branch block (Non-LBBB): 10 ± 6%, LBBB: 17 ± 7% (p <0.001).

Conclusion

This novel simplified approach by CCT can quantify dyssynchrony in different QRS duration and morphology groups. This method has promise for clinical applications to the evaluation of patients for CRT.

Abstract Figure.

Comparison between quantitative and subjective assessments of chemotherapy-induced peripheral neuropathy in cancer patients: A prospective cohort study

OBJECTIVE

Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse event experienced by cancer patients. In general, CIPN is evaluated subjectively based on patient self-assessment or clinician-reported scales; evidence supporting the utility and validity of quantitative sensory tests (QST) is lacking in this patient population. The aim of this study was to objectively assess CIPN of lower extremities by QSTs, and to evaluate the concordance between QSTs and subjective assessments.

METHODS

In this prospective cohort study, outpatients with cancer receiving chemotherapy were recruited at a single university hospital. We assessed CIPN at the lower extremities at baseline and three months after baseline. The QSTs were performed by applying a monofilament and a tuning fork to determine touch and vibration thresholds, respectively, at the affected site. Subjective assessments were performed based on the visual analog scale (VAS) and the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) toxicity grade. Kappa coefficients were calculated to evaluate the concordance between QSTs and subjective assessments.

RESULTS

After exclusion and drop-outs during follow-up, nineteen patients were included in the analysis. The prevalence of patients with abnormal sensation was 37% based on QSTs, 32% based on the VAS, and 14% based on CTCAE grading, respectively. Kappa coefficients were 0.32 between QSTs and VAS, and 0.28 between QSTs and CTCAE.

CONCLUSIONS

The concordance rates between quantitative and subjective assessments were low. CIPN should be assessed using both quantitative and subjective assessments.

Validation of the HFA-PEFF- and H2FPEF score in Japanese patients with heart failure with preserved ejection fraction

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) still remains challenging, and simple and reliable diagnostic tools have been required. Recently, novel and evidence-based diagnostic algorithms for HFpEF were proposed, such as H2FPEF score (Circulation. 2018) and HFA-PEFF score (Eur Heart J 2019), and their accuracy was validated in the outside patient group. However, there are regional and ethnic variations in patient characteristics of HFpEF, particularly between Western and Asian countries, and it is not elucidated whether these diagnostic scores are useful in Asian population.

Purpose

To investigate the validity of the HFA-PEFF- and H2FPEF score in Japanese patients with HFpEF.

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for HFpEF. The obtained scores were compared with the scores of the HFpEF cohort in the previous validation studies. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients hospitalized for HFpEF between June 2016 and August 2019 for the present study. H2FPEF score was obtained in 588 (77.7%) patients among them. Compared with the HFpEF cohorts in the previously reported sub-analysis of TOPCAT trial, the PURSUIT-HFpEF cohort had lower mean value of HFpEF score (4.0±1.8 points vs. 6.0±2.0 points in Americans or 5.3±1.9 points in Russians). It had significantly higher proportion (40.3%, p<0.001) of patients in the low likelihood of HFpEF category (0–3 points) than the TOPCAT cohorts (8.0% in Americans and 19.6% in Russians).

HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. The mean value of HFA-PEFF score was 5.0±0.8, and all patients had ≥2 points. The proportion of patients in the high likelihood of HFpEF category (5–6 points) was 88.3%, which was significantly higher (p<0.001) than those of the HFpEF cohort from Europe and USA in the previous validation study (Eur J Heart Fail 2019). There was no correlation between H2FPEF score and HFA-PEFF score (R=0.06, p=0.14). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE during follow-up period, whereas H2PEF score was not selected. Kaplan-Meier survival analysis demonstrated that patients with 6 points of HFA-PEFF score had higher incidence rate of MACE than those with ≤5 points (p=0.002).

Conclusion

The HFA-PEFF score could be more useful for the diagnosis and risk stratification for HFpEF than the H2PEF score in the Japanese cohort.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

High incidence of left atrial dysfunction and low voltage zone in patients requiring multiple atrial fibrillation ablation

Background

While multiple catheter ablation for recurrent atrial fibrillation (AF) is effective for the maintenance of sinus rhythm, some of patients have ablation-refractory AF. Left atrial (LA) dysfunction and the presence of low voltage zone (LVZ) are associated with recurrence after AF ablation. The association between recurrence and LA dysfunction/ LVZ among patients undergoing multiple AF ablation remains unclear.

Purpose

We aimed to compare (i)LA function, (ii)the prevalence of LVZ among patients undergoing first, second and third or more AF ablation procedures. Further, we investigated whether LA dysfunction and LVZ are associated with recurrence after multiple procedures.

Methods

We retrospectively analyzed 460 patients undergoing AF ablation procedures including first, second and third or more sessions from January 2017 to October 2019 in our institute. Before each session, 256-slice MDCT was performed under sinus rhythm to measure pre-ablation LA emptying fraction (LAEF) as the representative of LA function. At the end of each session, we checked the presence of LVZ, which was defined as regions where bipolar peak-to-peak voltage was <0.5mV. All patients underwent pulmonary vein isolation (PVI). If necessary, additional ablation (e.g. linear ablation, non-PV foci ablation and LVZ ablation) was performed.

Results

Out of 460 sessions, 295 were first (follow-up years: 1.5 [0.8, 2.0]), 134 were second (1.0 [0.5, 1.8]), and 31 were third or more sessions (1.2 [0.7, 2.0]). As the number of sessions increased, the recurrence rate was increased (19% vs. 31% vs. 61%, first vs. second vs. ≥third, P<0.0001), LAEF decreased (39.7±10.5% vs. 32.6±10.1% vs. 25.3±11.8%, P<0.0001) and the incidence of LVZ increased (18% vs. 34% vs. 68%, P<0.0001) (Figure 1). In patients with recurrence (N=104) after multiple ablation (second or more sessions), LAEF was lower and the prevalence of LVZ was higher than those without recurrence (N=61) (LAEF: 27.3±10.3% vs. 33.5±10.5%, with vs. without, P=0.0003; LVZ: 57% vs. 31%, P=0.0014).

Conclusions

As the number of sessions increased, the recurrence rate was increased. The prevalence of LA dysfunction and LVZ was high in patients requiring multiple ablation procedure. LA dysfunction and LVZ possibly reflect arrhytmogenic substrate causing recurrence of ablation-refractory AF. We should carefully consider repeated AF ablation in patients with severe LA dysfunction and extensive LVZ.

Figure 1

Funding Acknowledgement

Type of funding source: None

Pre-ablation left atrial function predicts the presence of low voltage zone in patients undergoing paroxysmal atrial fibrillation ablation: OLAF-LVZ predictive score

Background

Preoperative left atrial (LA) function is associated with paroxysmal atrial fibrillation (PAF) ablation outcome. The presence of left atrial low voltage zone (LVZ) is also associated with recurrence. We hypothesized that reduced pre-ablation LA function reflects the presence of LVZ.

Purpose

We investigated the association between baseline LA function and the presence of LVZ in patients undergoing initial PAF ablation. Further, we sought to create the new predictive scoring for the presence of LVZ.

Methods

Consecutive 305 patients who underwent LA voltage mapping during initial PAF ablation from January 2017 to October 2019 in our institute were retrospectively analyzed. We performed 256-slice MDCT at baseline. As the representative of LA function, we calculated LA emptying fraction (LAEF), where LAEF = {[(maximum LAV) − (minimum LAV)]/(maximum LAV)} x 100. LVZ was defined as regions where bipolar peak-to-peak voltage was <0.5mV. We performed the univariate and multivariate analysis to assess the association between LAEF and the presence of LVZ. Second, we performed receiver operating characteristic (ROC) analysis for the prediction of LVZ. We combined multivariate predictors and created the predictive scoring for LVZ.

Results

Out of 305 pts, 56 pts (18%) had LVZ in LA. In univariate analysis, low body mass index, higher percentage of female sex, higher age, higher E/e', larger maximum LA volume and lower LAEF (29.3±11.8% vs. 41.2±9.7, P<0.0001) was associated with the presence of LVZ. In multivariate logistic regression analysis, Low LAEF revealed the strongest predictor for LVZ (LAEF; Odds ratio [OR]/10% increase: 0.54, 95% CI: 0.39–0.82, P=0.0016). High age and female sex also remained as the independent predictors (Age; OR/10 y.o. increase: 1.80, 1.23–3.03, P=0.0042, Female; OR: 2.51, 1.15–5.49, P=0.0213). In ROC analysis, LAEF had moderate predictive accuracy for the presence of LVZ. (Area under the ROC curve: 0.77, Best cut-off value: 31%, P<0.0001) (Figure 1). We created OLAF-LVZ predictive score by combining Old age (1 point, ≥65), LAEF (2 points, LAEF ≤31%) and Female sex (1 point). OLAF score had gradient effect on the incidence of LVZ (2%, 11%, 25%, 45%, 71%, OLAF score; 0, 1, 2, 3, 4, respectively, P<0.0001) (Figure 2).

Conclusions

In PAF patients, preoperative LAEF was strongly associated with the presence of LVZ. LVZ might reflect the myocardial injury causing LA dysfunction. OLAF-LVZ predictive score: combination of Old age (≥65), Female sex, and LAEF (≤31%) could be useful to stratify the risk of the presence of LVZ.

Funding Acknowledgement

Type of funding source: None

Quantitative analysis of dyssynchrony assessed by multidetector computed tomography can predict clinical outcome after cardiac resynchronization therapy

Background

The degree of mechanical dyssynchrony has been suggested as a predictor for long-term survival after cardiac resynchronization therapy (CRT). There have been little reports of dyssynchrony assessment with the use of cardiac computed tomography (CCT).

Methods

We studied 35 heart failure (HF) patients (average age 67±10 years) referred for CRT with NYHA III-IV heart failure, left ventricular (LV) ejection fraction (EF) 20±10% (all ≤35%), and QRS duration 156±22 ms (all ≥120ms). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT was performed before CRT. Based on CCT, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and the time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software “Myocardial Contraction Map”. The standard deviation modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT. The predefined primary end-point was the first HF hospitalization or death over 2 years.

Results

%SD was feasible in all patients, respectably. There were 16 events over 2 years; 11 HF hospitalizations and 5 deaths. Patients with %SD ≥22% (optimal cutoff for outcome by ROC curve analysis) had a better clinical outcome than patients with %SD <22% (p=0.01, Figure).

Conclusion

Patients who had %SD ≥22% assessed by MDCT had a particularly favorable event-free survival following CRT, and this appears to be an important prognostic marker.

Funding Acknowledgement

Type of funding source: None

Evaluation of the local atrial function by regional speckle tracking imaging using intracardiac echocardiography

Background

It has been reported that low voltage areas and conduction abnormalities detected by electrophysiology catheters in the left atrium (LA) represent regional degeneration and fibrosis of the atrium and are related to a poor atrial fibrillation (AF) ablation outcome. Assessment of the local atrial function is clinically useful because atrial degeneration does not occur uniformly throughout the atrium. Though evaluating the global atrial function using speckle tracking imaging (STI) by transthoracic echocardiography (TTE) has been attempted, TTE does not have a sufficient image quality to assess local atrial STI.

Purpose

To evaluate the local atrial function by STI using intracardiac echocardiography (ICE) and to elucidate the characteristics of the STI in normal and abnormal voltage regions in the LA.

Methods

We included 9 patients undergoing AF ablation with written informed consent for this prospective observational study. After pulmonary vein isolation, we performed voltage mapping of the LA in sinus rhythm using a CARTO system (Biosense). Abnormal regions and normal regions were defined as those with low voltage areas (<0.5 mV) and those with normal voltages, respectively. Echo images were recorded by an ACUSON SC2000 (Siemens) and SOUNDSTAR catheter (Biosense). We inserted the SOUNDSTAR catheter into the LA to obtain clear images, recorded the STI of the anterior and inferior wall, and performed an offline analysis of the atrial strain with an eSie VVI work station (Siemens) and the LA voltage data with CARTO system at each site simultaneously (left figure). We compared the strain during the atrial contraction phase (Sct) between the normal and abnormal regions.

Results

Among the study population, 5 patients had low voltage areas in the LA. We evaluated the STI at 26 normal regions and 44 abnormal regions. The typical regional speckle tracking waveform in the normal region was similar to a jugular vein pressure waveform (right figure). There was a difference in the amplitude of the Sct between the groups; it was significantly smaller in the abnormal regions (normal and abnormal regions, 9.8±5.0% and 5.6±3.8%, p=0.0001). The duration of the Sct was significantly more prolonged in the abnormal regions than normal regions (98.8±26.3ms and 118.2±33.9ms, p=0.015).

Conclusions

This pilot study demonstrated that the local atrial function was evaluable by STI using ICE and that the regional strain tracking waveform during the atrial contraction phase in abnormal voltage regions was smaller and more prolonged than that in normal regions. An evaluation of the regional STI with an ICE may be useful to detect regional abnormalities of the atrium.

Representative case

Funding Acknowledgement

Type of funding source: None

1677 Global longitudinal strain during dobutamine stress echocardiography can predict left ventricular remodeling after anterior wall acute myocardial infarction

Background

Although dobutamine stress echocardiography (DSE) at the early stage of acute myocardial infarction (AMI) is useful for the prediction of functional and clinical prognosis, the interpretation requires expertise. In this study, we sought to investigate if global longitudinal strain (GLS) during DSE after AMI can predict left ventricular remodeling (LVR).

Methods

Consecutive 30 patients with anterior wall AMI (18 male, age = 58 ± 13 years) were performed DSE 3 days after AMI. GLS was calculated as an averaged value of peak longitudinal strain in the apical 4- and 2-chamber views at baseline echocardiography, low-dose DSE (10 μg/kg/min) using available software (QLAB, Philips Medical Systems). Left ventricular remodeling (LVR) was defined as an echocardiographically determined increase in both EDVI and ESVI of 20% or more from baseline to the 6 month follow-up echocardiography.

Results

12 patients (40%) evolved with LVR. The change in GLS during low-dose DSE was significantly different between the remodeling and non-remodeling group (8 ± 5% v.s. 27 ± 20%, p < 0.05). Interestingly, it predicted LVR with sensitivity of 88%, specificity of 92% at the cut-off value of 12% (Area under the curve = 0.94, p < 0.0001).

Conclusion

The change in GLS during low-dose DSE can be used as a predictor for the LVR after AMI. This observation has promise for clinical applications.

Abstract 1677 Figure.

Comparison of mediastinal lymph node metastases from adenocarcinoma of the esophagogastric junction versus lower esophageal squamous cell carcinoma with involvement of the esophagogastric junction

The distribution of mediastinal lymph node metastasis in patients with adenocarcinoma of the esophagogastric junction (AEG) remains unclear. Additionally, the distribution of nodal mediastinal metastasis from squamous cell carcinoma (SCC) of the lower esophagus with involvement of the esophagogastric junction remains unclear, given the very limited number of these patients. In this retrospective review, we compared the outcomes of radical lymphadenectomy of the mediastinum, including upper mediastinal lymphadenectomy, between patients with AEG and those with SCC. From 2005 to 2017, 69 consecutive patients underwent esophagectomy via right thoracotomy or minimally invasive esophagectomy for a Siewert type I or II tumor with esophageal invasion ≥3 cm. We analyzed the incidences of mediastinal lymph node metastasis in this group relative to those of 73 patients with SCC with involvement of the esophagogastric junction who consecutively underwent esophagectomy during the same period. Mediastinal lymph node metastasis was seen in 26 of 69 patients with AEG (38%), with upper, middle, lower mediastinal nodal metastasis instances of 20%, 17%, and 23%, respectively. Mediastinal lymph node metastasis was seen in 23 of 73 patients with SCC (32%), with upper, middle, lower mediastinal nodal metastasis instances of 12%, 16%, and 19%, respectively. This mediastinal lymph nodal metastasis distribution did not statistically differ between patients with AEG and those with SCC. The relapse-free survival outcomes were poor for patients with clinical (P < 0.01) or pathological (P < 0.01) nodal metastasis of the mediastinum with AEG. In contrast, patients with clinical or pathological mediastinal nodal metastases of SCC did not have extremely poor survival outcomes, compared to patients with AEG. Despite the limited dataset available for analysis, patients with AEG and those with SCC might exhibit similar incidences and distribution of mediastinal lymph node metastasis. However, the clinical or pathological metastasis of AEG to the mediastinum was associated with poor survival outcomes, even if radical mediastinal lymphadenectomy including the upper mediastinal lymphadenectomy was performed.

P3587Tip detection method using the new short-tip IVUS with pull-back system which facilitates the 3D wiring technique in percutaneous coronary intervention for chronic total occlusion

Background

The strategy of intravascular ultrasound (IVUS)-guided wiring for CTO PCI, that is, leading the second guidewire into the true lumen under observing by IVUS from subintimal space, is the last resort. We developed the angiography-based 3D wiring method. During establishment of the angiography-based 3D wiring method, we deduced that observation of the guidewire tip as well as the shaft named “The tip detection method” simplifies and facilitates 3D wiring under IVUS-guided wiring. Therefore, we produced New CTO IVUS which is the upgraded version of Navifocus WR IVUS by adding the pull-back transducer system. This pull-back system enables us to detect the tip as well as the shaft of the second guidewire in real time (tip detection method), which facilitates the 3D wiring technique under IVUS-guided wiring.

Objective

We evaluated the efficacy of the tip detection method during 3D wiring for CTO PCI with New CTO IVUS.

Method

We created a target pinpoint penetration model and performed the procedures using an experimental heartbeat model. The target (a tube with a lumen 0.6 mm in diameter) was placed in the distal part of a CTO 20 mm in length made of 2.5% agar. After the second guidewire (Conquest-12g) was advanced into the CTO lesion to within 5mm of the target using the angiography-based wiring, IVUS-guided wiring was performed by using Navifocus WR or New CTO IVUS each five times.

Result

The frequency of the puncture time was reduced using the new CTO IVUS compared to the Navifocus WR (1.7±0.8 vs. 28.8±23.2, p=0.17). The procedure time was significantly shorter using the new CTO IVUS compared to the Navifocus WR (103±61 vs. 459±373 seconds, p=0.04).

Conclusion

The tip detection method during 3D wiring with the new short tip IVUS with the pull-back system enables us to easily perform 3D wiring and will change the CTO PCI strategy.

P5750Manipulation strategy for crossing coronary chronic total occlusion: an update from the Japanese CTO-PCI expert registry

Background

The percutaneous coronary intervention (PCI) strategy for chronic total occlusion (CTO) based on the guidewire manipulation time remains infrequent.

Purpose

We aimed to assess CTO-PCI strategy on the basis of guidewire manipulation time.

Methods

A total of 5843 patients undergoing CTO PCI between January 2014 and December 2017 and enrolled in the Japanese CTO-PCI expert registry were assessed. Their CTO-PCI strategies, procedural outcomes, and guidewire manipulation time were analysed.

Results

The primary retrograde approach was performed on 1562 patients (26.7%). The overall guidewire and technical success rates were 92.8% and 90.6%, respectively. Median guidewire manipulation time of guidewire success and failure were 56 (interquatile range [IQR]: 22 to 111) min and 176 (IQR: 130 to 229) min, respectively. The average Japanese CTO score of the primary antegrade approach with the antegrade alone, the primary antegrade approach with the retrograde approach, and the primary retrograde approach were 1.7±1.1, 2.1±1.2, and 2.3±1.1, respectively (p<0.001). Median successful guidewire crossing time of single wiring in the antegrade alone was 23 (IQR: 11 to 44) min, and that of the primary retrograde approach was significantly shorter than that of the primary antegrade approach with the retrograde approach (107 [IQR: 70 to 161] min vs. 126 [IQR: 87 to 174] min; p<0.001). Reattempt, CTO length ≥20 mm, and proximal cap ambiguity were the predictors of guidewire failure in the primary antegrade approach with antegrade alone, but were not those in the primary retrograde approach.

Conclusions

Although successful guidewire crossing time of the primary antegrade approach with the antegrade alone is short, that of the primary retrograde approach can be shorter than that of the primary antegrade approach with the retrograde approach. Choosing an appropriate CTO-PCI strategy leads to shortening of successful guidewire crossing time.

P980Post-procedural plasma brain natriuretic peptide level early after catheter ablation predicts the future clinical outcome in patients with persistent atrial fibrillation and reduced ejection fraction

Background

Successful restoration of sinus rhythm (SR) by catheter ablation (CA) for persistent atrial fibrillation (AF) improves cardiac function, resulting in decrease of plasma brain natriuretic peptide (BNP) level. The exact significance and prognostic implications of this change have yet to be determined.

Purpose

To examine the impact of pre- and post-procedural BNP level on the clinical outcome after CA in patients with persistent AF and reduced left ventricular ejection fraction (LVEF).

Methods

Out of 242 patients with LVEF <50% who underwent first-time CA for persistent AF between March 2012 and September 2018 at our institute, we enrolled 137 patients (61±10 years, 83% male) whose plasma BNP level was available both at baseline and early after CA (during 1–3 month). We evaluated the impact of the BNP levels on future AF recurrence 3 months after CA as the primary endpoint. Additional secondary endpoints included heart failure (HF) hospitalization and cardiovascular death.

Results

All patients successfully restored SR at the end of CA. Within 3 months of a blanking period (BP), improvement of LVEF (from 39±10% to 65±12%, p<0.001) and reduction of BNP levels (from 178 [107–332] pg/ml to 42.3 [21.1–78.6] pg/ml, p<0.001) were observed. During the median follow-up of 21 months after BP, the incidence of AF recurrence, HF hospitalization, and cardiovascular death was 37% (n=50), 3% (n=4), and 1% (n=1), respectively. Cox proportional hazard regression analysis after adjustment for age and gender revealed that post-procedural BNP level was a significant predictor of the AF recurrence (hazard ratio [HR] per 100-pg/ml increase, 1.13; 95% confidence interval [CI], 1.02–1.25; p=0.023), but pre-procedural BNP level was not (1.02; 0.95–1.09; p=0.56). Receiver operating curve analysis determined the post-procedural BNP level of 55.5 pg/ml as the best cut-off value for predicting the AF recurrence, with area under the curve of 0.620 (95% CI, 0.534–0.702; p=0.018). The incidence of AF recurrence was significantly higher in patients with post-procedural BNP level >55.5 pg/ml (n=50) than the others (50% vs. 29%; HR, 3.99; 95% CI, 2.07–7.68; p<0.001). No patients with post-procedural BNP level ≤55.5 pg/ml experienced HF hospitalization and cardiovascular death (8% vs. 0% and 2% vs. 0%, p=0.006 and p=0.17, respectively)

Conclusions

Not pre-procedural but post-procedural BNP level early after CA predicted the future clinical outcome in patients with persistent AF and reduced LVEF. Decreased but still elevated BNP level after restoration of SR would identify the residual risk for developing unfavorable outcome.

Gamma-heavy chain monoclonal gammopathy with undetermined significance (MGUS)

Gamma-heavy chain disease (γ-HCD) is a rare B-cell tumor producing truncated IgG lacking the light chain. The clinical features of γ-HCD are heterogeneous, similar to lymphoplasmacytic lymphoma, and most patients have generalized and progressive disease. In some γ-HCD patients, autoimmune diseases are associated. Thus, γ-HCD as a restricted or indolent disease is exceptional. A 66-year-old male was referred to our hospital because of subungual hemorrhage at the bilateral halluces. Physical and laboratory examination results were nonspecific, and the hemorrhage was revealed to be traumatic. However, serum electrophoresis demonstrated a small M-peak, which was monoclonal IgG-Fc without the corresponding light chain on immunofixation and immunoelectrophoresis. Bone marrow aspirate demonstrated a small number of lymphoplasmacytic cells that were positive for CD19, CD38, CD138, and cyIgG, but negative for cyκ- and -λ light chains on flow cytometry. A diagnosis of γ-HCD was made. Chest and abdominal CT demonstrated neither hepatosplenomegaly, lymphadenopathy, nor bone lytic lesions. The serum concentrations of IgG and M-peak configuration have remained relatively unchanged for nearly 3 years. Therefore, this γ-HCD may correspond to a rare form of monoclonal gammopathy with undetermined significance.

Human herpesvirus 6 encephalitis in patients administered mycophenolate mofetil as prophylaxis for graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

BACKGROUND

Human herpesvirus 6 (HHV-6) encephalitis is a known life-threatening complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, few studies have focused on the occurrence of HHV-6 encephalitis in patients receiving mycophenolate mofetil (MMF) combined with a calcineurin inhibitor as prophylaxis for graft-versus-host disease (GVHD). This study aimed to investigate the impact of MMF administered for GVHD prophylaxis in the occurrence of HHV-6 encephalitis after allo-HSCT and the characteristics of this condition.

METHODS AND RESULTS

We retrospectively analyzed 73 patients who underwent allo-HSCT (83 transplants) at our hospital between April 2010 and December 2015. MMF (2-3 g/d) was administered along with a calcineurin inhibitor. Seven patients (8.0%) developed encephalitis due to HHV-6. The median period from allo-HSCT to the onset of HHV-6 encephalitis was 23 days (range, 17-98 days). The cumulative incidence of HHV-6 encephalitis on day 100 after treatment was 12% and 6% in patients who underwent cord blood transplantation (CBT) and non-CBT (ie, bone marrow transplantation and peripheral blood stem cell transplantation), respectively (P = 0.344). Neurological symptoms of encephalitis were more severe in non-CBT cases than those in CBT cases. All patients diagnosed with HHV-6 encephalitis were treated with ganciclovir or foscarnet. None of the enrolled patients died from HHV-6 encephalitis.

CONCLUSIONS

Mycophenolate mofetil may have the potential to increase the frequency of severe HHV-6 encephalitis in patients undergoing CBT and non-CBT. Thus, MMF should be administered with caution, and patients should be monitored closely for HHV-6 encephalitis even those who did not undergo CBT.

Clinical effects of recombinant thrombomodulin and defibrotide on sinusoidal obstruction syndrome after allogeneic hematopoietic stem cell transplantation

Sinusoidal obstruction syndrome (SOS) is a lethal complication after hematopoietic stem cell transplantation (HSCT). Defibrotide (DF) is the only drug internationally recommended for SOS treatment in Western countries. Recombinant human soluble thrombomodulin (rhTM), which is promising for the treatment of patients with disseminated intravascular coagulation, is also reported to be potentially effective for SOS. To clarify the safety and efficacy of DF and rhTM, we conducted a retrospective survey of these agents in Japan. Data from 65 patients who underwent allogeneic HSCT and received DF (n  =  24) or rhTM (n  =  41) for SOS treatment were collected. The complete response rates for SOS on day 100 were 50% and 54% in the DF and rhTM groups, respectively. The 100-day overall survival rates were 50% in the DF group, and 48% in the rhTM group. Several severe hemorrhagic adverse events were observed in one patient in the DF group and five patients in the rhTM group. The main causes of death were SOS-related death, and no patient died of direct adverse events of DF or rhTM. Our results suggest that rhTM, as well as DF, can be effective as a novel treatment option for SOS.

Oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment for squamous cell carcinoma of the oesophagus

Background

Treatment of supraclavicular nodes remains controversial among patients with oesophageal squamous cell carcinoma. This study assessed the outcomes of patients who underwent oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment.

Methods

This was a single-centre retrospective cohort study. Patients with oesophageal squamous cell carcinoma and clinically negative supraclavicular nodes who underwent oesophagectomy after neoadjuvant treatment between January 2005 and December 2015 were included. Overall and relapse-free survival were compared between patients who did or did not undergo supraclavicular nodal dissection. Propensity score matching was used to correct for differences in prognostic factors between the groups.

Results

Some 223 patients underwent supraclavicular lymphadenectomy. The prevalence of pathologically confirmed supraclavicular metastasis was 10·3 per cent, and these patients had poor 5-year relapse-free (7 per cent) and overall (14 per cent) survival. Only two of 55 patients who did not undergo supraclavicular lymphadenectomy had recurrent disease in the supraclavicular region without distant metastasis. There was no statistically significant difference between the groups in relapse-free survival (hazard ratio (HR) 0·95, 95 per cent c.i. 0·61 to 1·47; P = 0·821) or overall survival (HR 0·86, 0·52 to 1·40; P = 0·544). Similarly, no significant difference in relapse-free or overall survival was observed between the propensity score-matched groups.

Conclusion

For patients with clinically negative supraclavicular lymph nodes, prophylactic supraclavicular lymphadenectomy may be omitted when neoadjuvant treatment is administered.

Anemia Is a Novel Predictive Factor for the Onset of Severe Chemotherapy-Induced Peripheral Neuropathy in Lymphoma Patients Receiving Rituximab Plus Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone Therapy

Chemotherapy-induced peripheral neuropathy (CIPN) frequently occurs in lymphoma patients receiving R-CHOP, a drug combination therapy. Although severe CIPN may lead to reduction and/or discontinuation of the medication, predictive factors of CIPN have not been investigated sufficiently to date. We performed a retrospective exploratory research to determine associations between prevalence of severe CIPN and sociodemographic data, health characteristics, and medical conditions such as anemia at initial diagnosis. Forty patients (indolent lymphoma, n = 9; diffuse large B-cell lymphoma; n = 31) received R-CHOP therapy from September 2009 to July 2014. The median age of patients was 58 years (range = 27–76 years). Statistical analyses were applied to the patients, who were divided into two groups: mild CIPN (no symptoms or grade 1 according to the CTCAE version 3.0 program) and severe CIPN patients (grade 2 or higher). Forward stepwise logistic regression analyses were performed using the following variables: sex, BMI, BSA, hyperglycemia, malnutrition, and anemia. Severe CIPN occurred in seven patients (17.5%). Gender and anemia remained following the stepwise procedure, and anemia predicted severe CIPN significantly (OR = 19.45, 95% confidence interval = 1.52–171.12). Our study suggests that anemia at initial diagnosis could be a predictive factor of R-CHOP-induced CIPN.

Pharmacokinetics of intravenous mycophenolate mofetil in allogeneic hematopoietic stem cell-transplanted Japanese patients

PURPOSE

Mycophenolate mofetil (MMF) is increasingly used among Japanese patients undergoing allogeneic hematopoietic stem cell transplantation (allo-SCT). Because pharmacokinetic data for MMF in the Asian population are limited, we conducted this investigation.

METHODS

Intravenous MMF (1000 mg/dose) was administered to 10 patients along with cyclosporine or tacrolimus for 10 days after allo-SCT; it was administered every 8 h in peripheral blood stem cell- and bone marrow-transplanted patients, and every 12 h in cord blood-transplanted patients. MMF was administered orally at the same dose from day 11. Plasma concentrations of mycophenolic acid (MPA) were measured by high-performance liquid chromatography.

RESULTS

The MPA AUC_0 - tau was 31.9 ± 3.4, 26.2 ± 2.4, and 21.0 ± 2.2 µg*h/mL, the mean C_trough was 0.25, 0.35, and 0.37 µg/mL, and the C_max was 10.8, 9.2, and 5.5 µg/mL on days 2, 9, and 16, respectively. The AUC_0 - tau and C_max were significantly higher after intravenous MMF dosing than after oral MMF dosing. All patients exhibited successful neutrophil engraftments in a median time of 18 days. Grade II acute graft-versus-host disease (GvHD) of the skin was observed in two patients, and one patient developed limited chronic GvHD. Individual cases of transient and curable grade III oral mucositis and diarrhea were observed; however, MMF was not discontinued. No other severe complications or infections were observed.

CONCLUSIONS

Intravenously administered MMF was safe and possibly effective in achieving higher MPA plasma concentrations for GvHD prophylaxis after allo-SCT in Japanese patients.

Failure of neoadjuvant chemotherapy for resectable esophageal squamous cell carcinoma

Neoadjuvant treatment has become standard care for patients with resectable esophageal cancer. However, some patients cannot undergo surgery or curative resection because of disease progression during neoadjuvant treatment. The aim of this study is to identify the pretreatment characteristics of patients in whom neoadjuvant treatment failed. The study enrolled 231 patients who underwent chemotherapy with cisplatin and 5-fluorouracil (CF) as neoadjuvant therapy for T1N1-3 or T2-3 any-N esophageal squamous cell carcinoma (ESCC). Of these patients, 201 (87.0%) underwent curative resection (R0) and 30 (13.0%) could not undergo curative resection; 19 patients (8.2%) underwent incomplete resection (R1 or R2), and 11 patients (4.8%) could not undergo surgery because of disease progression. We compared clinical characteristics and survival between patients who underwent curative resection (curative group) and those who could not undergo curative resection (noncurative group) to determine the factors predicting noncurative treatment. The noncurative group had significantly worse disease-specific survival than the curative group (P < 0.001). All patients in the noncurative group had cT3 tumors. In 141 patients with cT3 tumors, those in the noncurative group were more likely to have higher serum SCC antigen concentration (P = 0.021), location of the main tumor in the upper to the middle third of the esophagus (P = 0.071), intramural metastases (P < 0.001), advanced N category (P = 0.016), and bulky lymph node metastases (P = 0.060). Multivariate logistic regression analysis identified location of the main tumor in the upper to the middle third of the esophagus (P = 0.047), intramural metastases (P = 0.002), and nodal metastases (N1, P = 0.014; N2, P = 0.015, respectively) as independent predictors of treatment failure in patients with cT3 tumors. Neoadjuvant CF therapy alone may not be effective for patients with cT3 tumors accompanied by these risk factors, and the efficacy of alternative strategies, such as triplet chemotherapy or chemoradiotherapy, should be evaluated.

Intensity and duration of neutropenia relates to the development of oral mucositis but not odontogenic infection during chemotherapy for hematological malignancy

Background

D-index which combines the intensity and duration of neutropenia is reported as a tool for evaluating the dynamics of neutropenia. This study aimed to analyze the relationship between D-index and oral complications (i.e., oral mucositis [OM] and odontogenic infection [OI]) during chemotherapies for hematological malignancies.

Methods

A total of 421 chemotherapeutic courses in 104 patients were analyzed. Chemotherapeutic courses in patients who finished all of the prophylactic dental treatments were defined as “treatment Finish”. Chemotherapeutic courses in patients who did not finish prophylactic dental treatments were defined as “treatment not-Finish”. OM was evaluated according to the Common Terminology Criteria for Adverse Events, version 4.0. D-index was compared between chemotherapeutic courses with versus without oral complications.

Results

D-index was significantly higher in chemotherapeutic courses with grade 1 or 2 OM (p < 0.001) than courses without OM. In contrast, higher D-index did not relate to the development of OI (p = 0.18). The occurrence of OI (p < 0.001) but not OM (p = 0.56) during chemotherapy was significantly higher in chemotherapeutic courses without the completion of dental intervention.

Conclusions

Higher D-index relates to the development of OM. In contrast, OI occurs due to untreated odontogenic foci, and its occurrence does not relate to higher D-index.

Methotrexate-associated lymphoproliferative disorders: management by watchful waiting and observation of early lymphocyte recovery after methotrexate withdrawal

No optimum treatment of iatrogenic immunodeficiency-associated lymphoproliferative disorders due to methotrexate in patients with rheumatoid arthritis (MTX-LPD) has yet been established, although MTX withdrawal is known to have a substantial effect on tumor regression. Here, we retrospectively analyzed 20 cases of MTX-LPD. Tumor shrinkage occurred in 18 of 20 cases, but only following MTX withdrawal. This tumor regression ratio was considerably better than in previous reports, and appeared due to longer "watchful waiting." Lymphocyte recovery at 2 weeks after MTX withdrawal was significantly higher in cases with tumor regression in 1 month than in those without tumor regression (p = 0.001). Median time to maximal efficacy after MTX cessation in cases without chemotherapy was 12 weeks (range 2-76). In conclusion, watchful waiting for a longer period after MTX cessation with observation of early lymphocyte recovery and uninterrupted continuation of other anti-rheumatoid drugs may be an acceptable management plan for MTX-LPD.

Rhabdomyolysis Caused by Candida parapsilosis in a Patient with Acute Myeloid Leukemia after Bone Marrow Transplantation

Rhabdomyolysis is characterized by a marked elevation of the creatine kinase (CK) levels and myoglobinuria, thus leading to renal dysfunction. Various viruses or bacteria can be etiologic agents, but mycosis has only rarely been reported to be a cause of rhabdomyolysis. In this report, we describe an adolescent male with acute myeloid leukemia who underwent allogeneic bone marrow transplantation and thereafter developed rhabdomyolysis and Candida parapsilosis fungemia almost at the same time. Following treatment for C. parapsilosis, the transaminase and CK levels both satisfactorily decreased. This case illustrates that C. parapsilosis infection may be a causative agent of rhabdomyolysis in immunocompromised patients.