Comparison of the Pre-Established and Finally Selected Treatment Strategies for Endovascular Treatment in Femoropopliteal Artery Lesions

This study aimed to compare lower limb events associated with preplanned and finally selected treatment strategies-the validity and usefulness of the physician-chosen strategy were verified.We examined the data of 1003 patients in the registry of multicenter endovascular treatment for superficial femoral and popliteal artery disease study and prospectively enrolled patients who underwent endovascular treatment (EVT) of the femoropopliteal (FP) artery between February 2017 and June 2018 from 67 Japanese institutes. The outcome measures were major adverse limb events (MALE) and target vessel revascularization.The EVT strategies were classified into balloon angioplasty-alone (37.3%), primary stenting (26.7%), and provisional stenting (36.0%) groups. In the initial strategy analysis for the balloon angioplasty-alone, primary stenting, and provisional stenting groups, two-year rates of freedom from MALE (95% confidence interval) were 0.680 (0.620-0.732), 0.754 (0.688-0.808), and 0.798 (0.746-0.840), respectively. Additionally, the rate of MALE was significantly higher among patients in the balloon angioplasty-alone group than among those in the primary or provisional stenting groups in the initial strategy analysis (P = 0.007). Changes in treatment strategy were more frequent in the primary stenting group than in the other groups. Furthermore, the rate of MALE did not significantly differ among the three groups in the final strategy analysis (P = 0.56).Limb outcomes for the final applied strategy did not differ among the three strategies. Additionally, the physician's selection bias was mostly appropriate in the EVT of the FP artery.

Infective endocarditis of transcatheter atrial septal occluder devices: A case report

Learning objective

Impact of catheter contact angle on lesion formation and durability of pulmonary vein isolation

Purpose

This study is aimed to evaluate the impact of catheter contact angle on lesion formation and durability of pulmonary vein isolation (PVI).

Methods

Both in vitro experiment and retrospective observational study were conducted. For in vitro experiment, radiofrequency lesions were created on explanted swine hearts in three different catheter contact angles (0°, 45°, and 90°). In the retrospective observational study, we assessed patients who had undergone repeat catheter ablation due to atrial fibrillation recurrence after initial PVI. When pulmonary vein (PV) reconnection was observed, we analyzed the previous ablation points within and without the gap area. The gap areas were where ablation had changed the PV activation sequence or eliminated the PV potential in the repeat session.

Results

In the in vitro experiment, lesion width was the smallest (5.3 ± 0.4 mm) in perpendicular contact compared to 0° (vs 5.8 ± 0.5 mm, p = 0.040) and 45° (vs 6.4 ± 0.4 mm, p < 0.001). In the retrospective observational study, we assessed 666 tags of 16 patients with PV reconnections, and 60 tags were in the gap area. Tags in the gap area had longer interlesion distance (odds ratio [OR] 1.49, p < 0.001), greater contact force variability (OR 1.03, p = 0.008), and higher rate of perpendicular contact (OR 3.26, p < 0.001) on multivariate analysis.

Conclusions

Perpendicular contact was associated with a smaller lesion and higher rate of PV reconnection.

Efficacy of treat-and-repair strategy for atrial septal defect with pulmonary arterial hypertension

OBJECTIVE

Therapeutic strategies for atrial septal defect (ASD) with severe pulmonary arterial hypertension (PAH) are controversial. This study aimed to evaluate the efficacy of PAH-specific medications and subsequent transcatheter closure (ie, treat-and-repair strategy) on clinical outcomes.

METHODS

We enrolled 42 patients who were referred to 13 institutions for consideration of ASD closure with concomitant PAH and underwent the treat-and-repair strategy. The endpoint was cardiovascular death or hospitalisation due to heart failure or exacerbated PAH.

RESULTS

At baseline prior to PAH-specific medications, pulmonary to systemic blood flow ratio (Qp:Qs), pulmonary vascular resistance (PVR), and mean pulmonary artery pressure (PAP) were 1.9±0.8, 6.9±3.2 Wood units and 45±15 mm Hg. Qp:Qs was increased to 2.4±1.2, and PVR and mean PAP were decreased to 4.0±1.5 Wood units and 35±9 mm Hg at the time of transcatheter ASD closure after PAH-specific medications. Transcatheter ASD closure was performed without any complications. During a median follow-up period of 33 months (1-126 months) after transcatheter ASD closure, one older patient died and one patient was hospitalised due to heart failure, but the other patients survived with an improvement in WHO functional class. PAP was further decreased after transcatheter ASD closure.

CONCLUSIONS

The treat-and-repair strategy results in low complication and mortality rates with a reduction in PAP in selected patients with ASD complicated with PAH who have a favourable response of medical therapy.

Impact of Frailty on Bleeding Events Related to Anticoagulation Therapy in Patients With Atrial Fibrillation

BACKGROUND

Although anticoagulation is the key treatment to prevent stroke in patients with atrial fibrillation (AF), including elderly patients, anticoagulation is sometimes withheld for elderly people because of concerns about frailty. However, it remains unknown whether frailty increases bleeding events.Methods and Results:A total of 120 consecutive non-valvular AF patients admitted with symptoms of AF or congestive heart failure were included in this study. Frailty was assessed using the Cardiovascular Health Study (CHS) frailty index. We performed a retrospective analysis of the risk factors associated with major bleeding events. After a median follow-up of 518 days, major bleeding events occurred in 17 (14.2%) patients. Patients with major bleeding events had a higher CHS frailty index (P=0.015). The cutoff value for high-risk CHS frailty index was 2 (area under the ROC curve: 0.68 [95% confidence interval (CI): 0.57-0.78]). The event-free rates at 2 years were 97.6% (95% CI: 83.9-99.7) in patients with a CHS frailty index <2 and 59.6% (95% CI: 27.9-81.0) for those with a CHS frailty index ≥2 (P<0.001).

CONCLUSIONS

Frailty is associated with increased bleeding events related to anticoagulant therapy in patients previously hospitalized with AF. Greater care should be taken with patients with a CHS frailty index ≥2.

Effects of angiotensin II receptor blockers on serum levels of epoxyeicosatrienoic acids and dihydroxyeicosatrienoic acids in patients admitted to a cardiovascular center

Purpose

Several clinical studies have demonstrated that angiotensin-converting enzyme inhibitors, but not angiotensin II receptor blockers (ARBs), reduce the risk of non-fatal myocardial infarction and cardiovascular mortality. We found that ARBs inhibited the activity of various cytochrome enzymes in arachidonic acid metabolism, resulting in decreased in vitro production of epoxyeicosatrienoic acids (EETs), which exhibit vasodilation and anti-inflammatory effects, and their subsequent metabolites, dihydroxyeicosatrienoic acids (DHETs). The present study examined the effects of ARBs on serum levels of EETs and DHETs in patients admitted to a cardiovascular center.

Methods

A total of 223 patients were enrolled, of which 107 were exposed to ARBs in this study. ARB-free individuals were defined as the control group (n = 116). Serum levels of EETs and DHETs were measured by liquid chromatography–tandem mass spectrometry. Multiple linear regression analyses were carried out to identify covariates for total serum levels of EETs and DHETs.

Results

A significant negative association was observed between ARB use and serum EET and DHET levels (p = 0.034), whereas a significant positive association was observed between the estimated glomerular filtration rate (eGFR) and serum EET and DHET levels (p = 0.007). The median serum total EET and DHET level in the ARB group tended to become lower than that in the control group, although the difference was not significant.

Conclusion

ARB use and eGFR were significantly associated with total serum levels of EETs and DHETs. Our results suggest that ARBs could affect the concentration of EETs in vivo.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-020-03061-1.

Remaining challenges in the diagnosis of early stage cardiac sarcoidosis

Despite the requirement for histopathological evidence to make a definite diagnosis of cardiac sarcoidosis, the sensitivity of endomyocardial biopsy is still low. Recently, Japanese Circulation Society suggests a new strategy that patients diagnosed clinically do not require the endomyocardial biopsy evidence. Physicians should familiarize themselves with such paradigm shifts.

Prevalence of Type A Acute Aortic Dissection in Patients With Out-Of-Hospital Cardiopulmonary Arrest

Postmortem computed tomography (PMCT) has been recently reported to be useful for detecting causes of death in the emergency department. In this study, the incidence and causes of death of type A acute aortic dissection (AAD) were investigated in patients who experienced out-of-hospital cardiopulmonary arrest (OHCPA) using PMCT. PMCT or enhanced computed tomography was performed in 311 of 528 consecutive patients experiencing OHCPA. A total of 23 (7%) of 311 patients were diagnosed with type A AAD based on clinical courses and CT findings. Eighteen consecutive patients who did not experience OHCPA were diagnosed with type A AAD during the same period. Pre-hospital death was observed in 21 (51%) of 41 patients with type A AAD. Bloody pericardial effusion was observed more frequently in patients who experienced OHCPA with type A AAD than in those who did not experience OHCPA with type A AAD (91% vs 28%, respectively; p <0.05). In conclusion, the incidence of type A AAD was common (7%) in patients who experienced OHCPA, with a high rate of pre-hospital death. Aortic rupture to the intrapericardial space was considered the major cause of death in patients who experienced OHCPA with type A AAD.

Anchoring technique to improve guiding catheter support in coronary angioplasty of chronic total occlusions

The primary reason for unsuccessful angioplasty of chronic total occlusions (CTOs) is an inability to pass the guidewire through the occlusion. Optimal guiding catheter support is a prerequisite for successful angioplasty of CTO. We performed guidewire manipulation by anchoring a balloon in a side-branch vessel in order to achieve adequate guiding catheter support. With this novel anchoring technique, we successfully achieved guidewire passage through the CTO.

Endovascular stent placement for isolated spontaneous dissection of the superior mesenteric artery: report of a case

Spontaneous dissection of the superior mesenteric artery (SMA) is rare and has been reported only sporadically. The therapeutic options are either a surgical approach, which is the most frequently adopted, or simple observation. We present a patient with acute abdominal pain due to superior mesenteric artery dissection who was successfully treated by percutaneous endovascular stent placement.

Acetylcholine-induced coronary spasm with a history of Kawasaki disease: case report

A 21-year-old woman without any known coronary risk factors was found at coronary catheterization to have normal coronary angiograms, but demonstrated acethylcholine (ACh)-induced coronary spasm. She had a history of Kawasaki disease (KD) at 19 months of age and, although coronary angiography was not performed at that time, no coronary aneurysms were detected by echocardiography. To the best of our knowledge, this is the first case report of ACh-induced coronary spasm associated with normal coronary angiograms in a young person with a history of KD. The findings suggest that subclinical, persistent coronary endothelial dysfunction may exist in this patient; furthermore, the dysfunction appears diffuse and might be unrelated to coronary aneurysm formation. The long-term significance of coronary endothelial dysfunction in patients with KD, as suspected by coronary spasm, remains unknown but may be an important risk factor for future atherosclerosis.

Acetylcholine measurement of cerebrospinal fluid by in vivo microdialysis in freely moving rats

Acetylcholine (ACh) and choline (Ch) levels in rat cerebrospinal fluid (CSF) were determined by in vivo microdialysis (CSF microdialysis) in both halothane-anesthetized and freely-moving rats. The Ch/ACh ratio in CSF perfused with Ringer's solution (30 microliters/30 min) containing 10(-5) M physostigmine, a centrally active cholinesterase inhibitor, was significantly lower than that in unprocessed CSF due to significantly higher ACh levels in the former. The successive measurement on the 2nd and 7th day after the guide cannula implantation demonstrated the feasibility of the CSF microdialysis method for repetitive monitoring of CSF ACh and Ch levels in freely moving rats without extensive tissue damage. Intraperitoneal administration of physostigmine caused an increase in CSF ACh levels, whereas administration of neostigmine, which cannot penetrate into the blood brain barrier, did not. Furthermore, a centrally active acetylcholinergic M1-receptor agonist, AF102B, produced an increase in CSF ACh and Ch levels. Thus, the present study demonstrates that CSF microdialysis is a useful method for evaluating overall central cholinergic activity and investigating the pharmacological effects of various drugs that act via the central cholinergic system.

The functional role of opioid receptors in acetylcholine release in the rat adrenal medulla

The functional role of opioid receptors in acetylcholine release from splanchnic nerve terminals in the adrenal medulla was investigated in halothane-anesthetized rats. The extracellular acetylcholine level was measured by a newly developed in vivo adrenal microdialysis method. The potassium (K+)-evoked acetylcholine release from the splanchnic nerve terminals was inhibited by morphine (10 microM), a mu-opioid receptor agonist, and [D-Pen2,D-Pen5]enkephalin (DPDPE, 1 and 10 microM), a delta-opioid receptor agonist. These inhibitory effects of morphine and DPDPE were significantly abolished by naltrexone (9 mg/kg i.p.), a mu-opioid receptor antagonist, and naltrindole (9 mg/kg i.p.), a delta-opioid receptor antagonist, respectively. 5 alpha,7 alpha-beta-(-)- N-methyl-N-[7-(1-pyrrolidinyl)-1-oxaspiro(4,5)dec-8-yl]benzene acetamide (U69593, 10 microM), a kappa-opioid receptor agonist, had no influence on the K(+)-evoked acetylcholine release. The findings suggest that both mu- and delta-opioid receptors might have a functional role in acetylcholine release from splanchnic nerve terminals in the adrenal medulla of the rat. The present study indicates that adrenal microdialysis is a useful method for studying the control mechanism of adrenomedullary function in the rat in vivo.

mu-Opioid receptors modulate noradrenaline release from the rat hippocampus as measured by brain microdialysis

The modulation of noradrenaline (NA) release via presynaptic opioid receptors in the hippocampus of freely moving rats was studied by the use of brain microdialysis. Extracellular levels of NA were estimated by assaying its concentrations in the perfusion fluid using high-performance liquid chromatography (HPLC) with electrochemical detection (ECD). Spontaneous NA levels were reduced by tetrodotoxin (1 microM) co-perfusion and were increased by peripheral administration of desipramine (5 and 10 mg/kg, i.p.). Addition of potassium (K+, 60 and 120 mM) to the perfusion fluid evoked a concentration-dependent release of NA. K+ (120 mM)-evoked NA release was markedly reduced by removal of calcium (Ca2+) from the perfusion fluid. These results indicate that both the spontaneous and the K(+)-evoked NA release measured by the use of brain microdialysis coupled with HPLC-ECD can be used as indices of neuronal release from the noradrenergic nerve terminals. A mu-opioid receptor agonist, morphine (0.01-10 microM), when co-perfused with K+ (120 mM), produced a reduction of K(+)-evoked NA release in a concentration-dependent manner. Neither co-perfusion with a high concentration of [D-Pen2, D-Pen5]-enkephalin (DPDPE) (10 microM), an agonist selective for delta-opioid receptors, nor with U-69593 (10 microM), an agonist selective for kappa-opioid receptors, modified the K+ (120 mM)-evoked release of NA. Morphine-induced (1 microM) inhibition of NA release was blocked by a mu-opioid receptor antagonist, naltrexone (3 and 9 mg/kg, i.p). Naltrexone by itself did not alter the spontaneous NA levels or the K(+)-evoked NA release.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurochemical profiles in cerebrospinal fluid of stroke-prone spontaneously hypertensive rats

The purpose of the present study was to evaluate stroke-prone spontaneously hypertensive rats (SHRSP) neurochemically by determining the cerebrospinal fluid (CSF) levels of acetylcholine (ACh), norepinephrine (NE) and serotonin (5-HT) as an index of central neuronal activity. The CSF ACh levels of 15- to 20-week-old SHRSP were significantly lower than those of age-matched Wistar Kyoto rats (WKY) both under the urethane/alpha-chloralose anesthesia and in freely moving conditions. The difference in the CSF ACh levels between SHRSP and WKY was more marked at 30-40 weeks. Sustained changes were not observed in the CSF NE and 5-HT levels. Thus, the progressive dysfunction in the central cholinergic system may characterize the pathophysiological state of this animal model with cerebral lesions caused by continuous high blood pressure.

Inhibitory effects of clonidine on serotonergic neuronal activity as measured by cerebrospinal fluid serotonin and its metabolite in anesthetized rats

Clonidine-induced changes in the serotonergic neuronal activity of the central nervous system were estimated by measuring the concentrations of serotonin (5-HT) and its major metabolite, 5-hydroxyindole-3-acetic acid (5-HIAA), in the cerebrospinal fluid (CSF) of anesthetized rats. Clonidine (30 and 300 micrograms/kg, i.v.) led to 74% and 60% reductions in the concentration of 5-HT in the CSF 60 min after administration. CSF 5-HIAA concentrations were also decreased to 77% and 66%, respectively. Clonidine-induced (30 micrograms/kg, i.v.) decreases in CSF 5-HT and 5-HIAA concentrations were attenuated by pretreatment with idazoxan (5 mg/kg, i.p.). Idazoxan by itself did not alter the CSF 5-HT and 5-HIAA concentrations. Decreased CSF 5-HT and 5-HIAA concentrations after i.v. administration of clonidine (30 micrograms/kg) were abolished by noradrenergic denervation after pretreatment with 6-hydroxydopamine (200 micrograms/rat, i.c.v.). These results suggest the possibility that clonidine acts to inhibit the serotonergic neuronal activity, which is mediated via the alpha 2-adrenoceptors. It indicates, moreover, that noradrenergic nervous systems are involved in the clonidine-induced inhibition of serotonergic neuronal activity. Therefore, noradrenergic neurons play a significant role in mediating the actions of clonidine on serotonergic neuronal activity in the rat brain.

Significant correlation between cerebrospinal fluid and brain levels of norepinephrine, serotonin and acetylcholine in anesthetized rats

The present study was undertaken to determine cerebrospinal fluid (CSF) and brain levels of norepinephrine (NE), serotonin (5-HT) and their metabolites--3,4-dihydroxyphenylacetic acid (DOPAC), 4-hydroxy-3-methoxyphenylacetic acid (HVA) and 5-hydroxyindole-3-acetic acid (5-HIAA)--in rats pretreated with 6-hydroxydopamine (6-OHDA) or 5,7-dihydroxytryptamine (5,7-DHT). In the 6-OHDA pretreated rats, both CSF and brain concentrations of NE, DOPAC and HVA sustained significant decreases as compared with those in non-treated rats. Positive and significant correlations between CSF and brain levels were observed in respect to NE, DOPAC and HVA. In 5,7-DHT pretreated rats, both CSF and brain concentrations of 5-HT and 5-HIAA were significantly decreased. A positive and significant correlation between CSF and brain levels in respect to 5-HT and 5-HIAA was observed. Further studies were carried out to determine ACh levels of both the CSF and the brain in microspheres (MS)-treated rats, which are used as a model of microembolization. The CSF ACh concentrations in MS-treated groups were significantly decreased as compared with those in non-treated rats. The brain ACh contents also tended to decrease in this group. A positive and significant correlation was observed between CSF and brain levels of ACh. These findings suggest that NE, 5-HT and ACh concentrations in the CSF are direct indications of central noradrenergic, serotonergic and cholinergic nerve activity, respectively.

Simultaneous high-performance liquid chromatographic determination of norepinephrine, serotonin, acetylcholine and their metabolites in the cerebrospinal fluid of anaesthetized normotensive rats

A high-performance liquid chromatographic method with electrochemical detection was developed for the simultaneous determination of the levels of norepinephrine (NE), serotonin (5-HT), acetylcholine (ACh) and their metabolites in the cerebrospinal fluid (CSF) of anaesthetized rats. The response curve for each compound was linear for the concentration way of interest. The within- and between-day coefficients of variation (C.V.) for NE, 5-HT and their metabolites were less than 7.85% and 15.67%, respectively, and those for ACh and choline were less than 3.08% and 6.27%, respectively. This simultaneous determination should be useful for elucidating the noradrenergic, serotonergic and cholinergic nerve activity in the central nervous system.

Decreased monoamine oxidase activity in stroke-prone spontaneously hypertensive rat kidneys

The present study was undertaken to measure kidney monoamine oxidase activity (MAO) isolated from three different rat groups: Wistar Kyoto rats (WKY), stroke-free cases of stroke-prone spontaneously hypertensive rats (SHRSP-control) and SHRSP-stroke cases (SHRSP-stroke). The SHRSP group was found to have less kidney MAO than the WKY group. Conversely, plasma norepinephrine concentration of SHRSP group was significantly higher than that of the WKY group (Jpn. Heart J., 25, 833-835, 1985). These findings suggest that the increased blood pressure in SHRSP may be related to increased plasma norepinephrine concentration caused by a decrease in degradation enzyme, MAO. An attempt was also made to determine the effects of clorgyline and deprenyl. No significant difference in MAO was observed between the kidneys isolated from the WKY, SHRSP-control and SHRSP-stroke groups. However, the inhibition curve of clorgyline reached a plateau after producing 33% inhibition of MAO. It was assumed that rat kidney mitochondrial MAO consists of 33% MAO-A type and 67% MAO-B type.

[Effect of ketanserin on blood pressure in rats]

Ketanserin, a selective serotonergic (5-HT2) antagonist, also has affinity for alpha 1-adrenoceptors. It is not clear whether the hypotensive mechanism of ketanserin is due to its antagonistic action to 5-HT2 receptor or to its affinity for alpha 1 adrenoceptors. The hypotensive mechanism of ketanserin was studied in both stroke-prone spontaneously hypertensive rats (SHRSP) and Wistar Kyoto rats (WKY). Anesthetized rats were used (alpha-chloralose + urethane, i.p.). Up to 3 ml of blood was drawn from each rat for analysis. Plasma norepinephrine (NE) was determined by radioenzymatic assay. Plasma serotonin (5-HT) was determined by HPLC-ECD. Adrenal nerve discharges were counted by a digital pulse counter. Ketanserin (0.5 mg/kg, 5.0 mg/kg, i.v.) produced a dose-dependent reduction of mean arterial pressure (MAP) in both SHRSP and WKY. MAP of SHRSP decreased significantly as compared with WKY. Both plasma NE and 5-HT showed a tendency to increase during ketanserin administration (5.0 mg/kg, i.v.). Ketanserin significantly antagonized the BP response induced by exogenously injected 5-HT (30 micrograms/kg) and NE (10 micrograms/kg). Adrenal nerve activity was reduced in parallel with the decrease in BP and HR. These findings suggest that ketanserin produced a decrease in BP via both peripheral and central action in rats.