Iodine contrast volume reduction in preoperative transcatheter aortic valve implantation computed tomography: Comparison with 64- and 256-multidetector row computed tomography

INTRODUCTION

This study aimed to compare the vascular enhancement and radiation dose in preoperative transcatheter aortic valve implantation (TAVI) computed tomography (CT) with a reduced contrast medium (CM) using volume scans in 256-multidetector row CT (MDCT) with a standard CM using 64-MDCT.

METHODS

This study included 78 patients with preoperative TAVI CT with either 64- or 256-MDCT. The CM was injected at 1.5 mL/kg in the 64-MDCT group and 1.0 mL/kg in the 256-MDCT group. We compared vascular enhancement of the aortic root and access routes, image quality (IQ) scores, and radiation dose in both groups.

RESULTS

Despite the reduced CM (by 33 %) in the 256-MDCT group, the mean vascular enhancement of the right and left subclavian arteries was significantly higher than that in the 64-MDCT group [284 and 267 Hounsfield units (HU) vs. 376 and 359 HU; p < 0.05]; however, no significant differences in the mean vascular enhancement in the ascending aorta, abdominal aorta at the celiac level, and bilateral common femoral arteries were observed between the two groups (p > 0.05 for all). The median IQ scores at the aortic root were higher in the 256-MDCT group than in the 64-MDCT group (3 vs. 4; p < 0.05), and those at the femoral access routes were comparable (4 vs. 4; p = 0.33). The mean effective dose was significantly reduced by 30 % in the 256-MDCT group (23.6 vs. 16.3 mSv; p < 0.05).

CONCLUSION

In preoperative TAVI CT, volume scans using 256-MDCT provide comparable or better vascular enhancement and IQ with a 30 % reduction in CM and radiation dose than those using 64-MDCT.

IMPLICATIONS FOR PRACTICE

Volume scan using 256-MDCT for preoperative TAVI CT may reduce CM and radiation dose in TAVI patients with renal dysfunction.

Gamete-exporting organs of vertebrates: dazed and confused

Mature gametes are transported externally for fertilization. In vertebrates, the gonads are located within the coelom. Consequently, each species has specific organs for export, which often vary according to sex. In most vertebrates, sperm ducts and oviducts develop from the Wolffian and Müllerian ducts, respectively. However, exceptions exist. Both sexes of cyclostomes, as well as females of basal teleosts, lack genital ducts but possess genital pores. In teleosts of both sexes, genital ducts are formed through the posterior extensions of gonads. These structures appear to be independent of both Wolffian and Müllerian ducts. Furthermore, the development of Wolffian and Müllerian ducts differs significantly among various vertebrates. Are these gamete-exporting organs homologous or not? A question extensively debated around the turn of the 20th century but now largely overlooked. Recent research has revealed the indispensable role of Wnt4a in genital duct development in both sexes of teleosts: zebrafish and medaka. wnt4a is an ortholog of mammalian Wnt4, which has functions in Müllerian duct formation. These results suggest a potential homology between the mammalian Müllerian ducts and genital ducts in teleosts. To investigate the homology of gamete-exporting organs in vertebrates, more detailed descriptions of their development across vertebrates, using modern cellular and genetic tools, are needed. Therefore, this review summarizes existing knowledge and unresolved questions on the structure and development of gamete-exporting organs in diverse vertebrate groups. This also underscores the need for comprehensive studies, particularly on cyclostomes, cartilaginous fishes, basal ray-finned fishes, and teleosts.

Diversity and evolution of serotonergic cells in taste buds of elasmobranchs and ancestral actinopterygian fish

A subset of gustatory cells are serotonin immunoreactive (ir) in the mammalian taste bud. In the taste bud of lamprey, elongated gustatory-like cells are also serotonin-ir. In contrast, flattened serotonin-ir cells are located only in the basal region of the taste buds in the teleosts and amphibians. These serotonin-ir cells are termed as basal cells. To evaluate the evolution and diversity of serotonergic cells in the taste bud of amniote animals, we explored the distribution and morphology of serotonin-ir cells in the taste buds of ancestral actinopterygian fish (spotted gar, sturgeon, Polypterus senegalus) and elasmobranch (stingray). In all examined animals, the taste buds contained serotonin-ir cells in their basal part. The number of serotonin-ir basal cells in each taste bud was different between these fish species. They were highest in the stingray and decreased in the order of the Polypterus, sturgeon, and gar. While serotonin immunoreactivity was observed only in the basal cells in the taste buds of the ancestral actinopterygian fish, some elongated cells were also serotonin-ir in addition to the basal cells in the stingray taste buds. mRNA of tryptophan hydroxylase 1 (tph1), a rate-limiting enzyme of the serotonin synthesis, is expressed in both the elongated and basal cells of stingray taste buds, indicating that these cells synthesize the serotonin by themselves. These results suggest that the serotonin-ir basal cells arose from the ancestor of the cartilaginous fish, and serotonin-ir cells in the elasmobranch taste bud exhibit an intermediate aspect between the lamprey and actinopterygian fish.

Time-, spin-, and angle-resolved photoemission spectroscopy with a 1-MHz 10.7-eV pulse laser

We describe a setup of time-, spin-, and angle-resolved photoemission spectroscopy (tr-SARPES) employing a 10.7 eV (λ = 115.6 nm) pulse laser at a 1 MHz repetition rate as a probe photon source. This equipment effectively combines the technologies of a high-power Yb:fiber laser, ultraviolet-driven harmonic generation in Xe gas, and a SARPES apparatus equipped with very-low-energy-electron-diffraction spin detectors. A high repetition rate (1 MHz) of the probe laser allows experiments with the photoemission space-charge effects significantly reduced, despite a high flux of 1013 photons/s on the sample. The relatively high photon energy (10.7 eV) also brings the capability of observing a wide momentum range that covers the entire Brillouin zone of many materials while ensuring high momentum resolution. The experimental setup overcomes the low efficiency of spin-resolved measurements, which gets even more severe for the pump-probed unoccupied states, and affords the opportunity to investigate ultrafast electron and spin dynamics of modern quantum materials with energy and time resolutions of 25 meV and 360 fs, respectively.

Search for Gamma-Ray Spectral Lines from Dark Matter Annihilation up to 100 TeV toward the Galactic Center with MAGIC

Linelike features in TeV γ rays constitute a "smoking gun" for TeV-scale particle dark matter and new physics. Probing the Galactic Center region with ground-based Cherenkov telescopes enables the search for TeV spectral features in immediate association with a dense dark matter reservoir at a sensitivity out of reach for satellite γ-ray detectors, and direct detection and collider experiments. We report on 223 hours of observations of the Galactic Center region with the MAGIC stereoscopic telescope system reaching γ-ray energies up to 100 TeV. We improved the sensitivity to spectral lines at high energies using large-zenith-angle observations and a novel background modeling method within a maximum-likelihood analysis in the energy domain. No linelike spectral feature is found in our analysis. Therefore, we constrain the cross section for dark matter annihilation into two photons to ⟨σv⟩≲5×10^{-28}  cm^{3} s^{-1} at 1 TeV and ⟨σv⟩≲1×10^{-25}  cm^{3} s^{-1} at 100 TeV, achieving the best limits to date for a dark matter mass above 20 TeV and a cuspy dark matter profile at the Galactic Center. Finally, we use the derived limits for both cuspy and cored dark matter profiles to constrain supersymmetric wino models.

Precise pulsed magnetic field mapping using a compact pick-up probe for a pulsed sextupole magnet

A pulsed sextupole magnet was used for beam injection at the KEK-Photon Factory (KEK-PF). During the top-up injection, oscillation of the stored beam was observed. To investigate this issue, a compact pick-up probe has been developed for measuring peak fields around the zero-magnetic-field region where the stored beam passes. The probe has two coils: a main coil and a background coil. The width and length of the main coil are only 3.2 and 5.8 mm, respectively. The voltage signal from the background coil is subtracted from that of the main coil to obtain an effective voltage signal. The results show that the peak field of a pulsed magnet can be measured with a sufficient accuracy for magnetic field mapping. A magnetic field signal with an amplitude of 2.2 × 10^-4 T was measured clearly. The longitudinal field structure that contains the magnetic field generated by the eddy-current effect was observed, which explains the oscillation of the stored beam at the KEK-PF.

Prognosis of hypertrophic cardiomyopathy in Japanese patients with an implantable cardioverter defibrillator -focus on apical hypertrophic cardiomyopathy

Background

Patients with hypertrophic cardiomyopathy (HCM) are at high risk of lethal arrhythmias, and implantable cardioverter defibrillators (ICD) are widely used for prevention of sudden cardiac death (SCD). Apical HCM is a phenotype variant of HCM, with hypertrophy predominantly affecting apex, that was initially described 30 years ago. Apical HCM patients may have different clinical prognosis compared with other subsets of HCM. In previous studies, apical HCM patients seem to have a more benign prognosis than other types of HCM. However, little is known about the long-term outcomes of apical HCM patients and there are many unclear points. Moreover, there are few reports about the clinical prognosis in apical HCM patients with an ICD.

Objective

The aim of this study is to identify the difference between the prognosis of apical and the other types of HCM patients with an ICD.

Methods

We retrospectively analyzed the database of our ICD clinic. All subjects underwent ICD implantation between October 2006 and September 2018. We classified HCM patients into LV outflow tract obstruction (LVOTO) and midventricular obstruction (MVO), apical HCM and other non-obstructive types. We divided all the patients into apical and other types of HCM, and examined their background, incidence of appropriate ICD therapies, hospitalization for heart failure, electrical storm and death.

Results

A total of consecutive 64 Japanese HCM patients with an ICD (follow-up period, 86±24 months; age, 65±14 years; male sex, 83%; left ventricular ejection fraction, 56±14%; LV max wall-thickness, 19±7mm; LV apical aneurysm, 9.4%; 5-year risk of SCD, 4.4±2.1) were enrolled in this study. We classified them into 14 apical HCM and 50 other types of HCM patients. The clinical characteristics and major clinical events of these patients are shown in the Table 1. During the follow-up periods, there were no significant differences in the incidence of electrical storm, hospitalization for heart failure and death between the 2 groups (p=0.11; p=0.60; p=0.39). Appropriate ICD therapies occurred in 6 of 14 (43%) patients with apical HCM and 5 of 50 (10%) patients with other types of HCM (p=0.010). The risk factors of patients with apical HCM patients are shown in Table 2.

Conclusions

Appropriate ICD therapy was more prevalent in patients with apical HCM, compared to patients with other types of HCM. Aggressive intervention such as catheter ablation for ventricular tachycardia and ventricular fibrillation may be considered in patients with apical HCM and higher score of 5-year risk of SCD. Further studies are needed to clarify the manifestations and long-term outcome of apical HCM patients.

Funding Acknowledgement

Type of funding sources: None.

Long-term clinical course and prognostic factors of heart failure with reduced ejection fraction (HFrEF) patients underwent primary prophylactic implantable cardioverter defibrillator (ICD)

Background

For decades, ICD is a well-established therapy for improving prognosis of structural heart disease with severe cardiac dysfunction, and ICD for primary prophylaxis against sudden cardiac death were routinely provided. However, long-term prognosis and clinical course are different in each individual patient with an ICD, and it is moreover unclear what kind of factors might have influences on their clinical outcomes.

Purpose

The aim of this study is to clarify long-term prognosis and predictors of future major adverse cardiac events (MACEs) in HFrEF patients with an ICD as primary prophylaxis in Japanese population.

Methods

We retrospectively analyzed our ICD database. Patients underwent primary prophylactic ICD implantation from 2006 to 2020 at our institute and met the criteria of ICD recommendation of the latest Japanese guideline. Its requirements are receiving optimal medication therapy, symptomatic heart failure (New York Heart Association classification II or greater), and severe cardiac dysfunction (left ventricular ejection fraction (LVEF) is 35% or less). Additionally, prior NSVT is considered Class I ICD recommendation. In the case of ischemic cardiomyopathy (ICM), ICD implantation was done at least 40 days after myocardial infarction and at least 90 days after revascularization. MACEs were defined as composite outcome of cardiovascular death, heart failure hospitalization, and appropriate ICD therapies.

Results

A total of 148 consecutive patients were enrolled (male, 120 (81%); age, 62.1±11.8 years; LVEF, 23.0±5.86%; left ventricular end-diastolic diameter (LVDd), 67.6±9.26mm; paroxysmal or persistent atrial fibrillation (AF), 38 (26%); NSVT, 113 (76%); use of class III antiarrhythmic drugs, 48 (32%); ICM, 49 (33%); cardiac resynchronization therapy (CRT), 63 (43%)). One hundred twenty patients (81%) were programmed with a shock-only zone over 200 beats per minute. The median follow-up duration was 58.5 months. Among those 148 patients, MACEs were occurred to 60 patients (41%). As a result of dividing all patients into two groups by the occurrence of MACE, LVEF and LVDd were worse in MACE(+) group, whereas, MACE(−) had greater number of co morbidities. The results of cox-regression analysis showed LVDd (HR: 1.07, 95% CI: 1.03–1.12, p&lt;0.001), AF (HR: 2.88, 95% CI: 1.56–5.31, p&lt;0.001) and ICM (HR: 1.78, 95% CI: 1.00–3.16, p=0.049) were the independent predictors of MACEs (Table). However, initial ICD programming was not related to the occurrence of MACE.

Conclusions

The incidence of MACEs in patients with an ICD and severe HFrEF was substantially high in this Japanese population. Etiology of ICM, left ventricle size, and AF were the potential risk factors for future MACEs.

Funding Acknowledgement

Type of funding sources: None.

Clinical findings of triglyceride deposit cardiomyovasculopathy

Background

Triglyceride (TG) deposit cardiomyovasculopathy (TGCV) is a novel cardiovascular disorder and was recently encoded as an orphan disease in Europe (ORPHA code: 565612). Defective intracellular lipolysis results in TG accumulation in the myocardium and coronary arteries in TGCV. The myocardial washout rate (WR) of iodine-123-β-methyl-p-iodophenylpentadecanoic acid (BMIPP) is an essential indicator to evaluate myocardial lipolysis in vivo, and decreased WR (&lt;10%) of BMIPP is one of the essential items of diagnostic criteria for TGCV.

Purpose

To clarify clinical findings of TGCV including comorbid conditions and laboratory findings.

Methods

We enrolled 234 patients who underwent BMIPP scintigraphy between September 2015 and July 2019. The distributions of TGCV in each comorbidity, cardiac functions and laboratory findings were investigated.

Results

In total, 104 patients were diagnosed with definitive TGCV. The BMIPP WR of TGCV patients was −1.37±10.6%. TGCV patients had various comorbid conditions, including coronary artery disease (75%), diabetes mellitus (56%), and heart failure (21%). Left ventricular ejection fraction (LVEF) of TGCV patients was significantly lower than that of non-TGCV patients (38.1±18.0% vs. 43.6±18.9%, p-value=0.026). Moreover, among those who did not take lipid-lowering drugs, there was no difference in the serum TG level between TGCV and non-TGCV patients (TGCV: n=44, 127±84.6 mg/dL, non-TGCV: n=66, 133±70.7 mg/dL, p-value=0.73).

Conclusions

TGCV patients showed multiple coexistence of coronary artery disease, diabetes mellitus, or heart failure with lower LVEF. Serum TG level was not significantly different between TGCV and non-TGCV patients. Serum TG did not affect the intracellular TG accumulation in TGCV patients directly, and this result was consistent with the pathophysiological hypothesis that the TG accumulation in the myocardial cytoplasm is due to intracellular lipase dysfunction.

Funding Acknowledgement

Type of funding sources: None.

Impact of right ventricular reserve on exercise capacity and quality of life in patients with left ventricular assist device

Background

Right heart failure following left ventricular assist device (LVAD) implantation is a major complication which significantly impairs functional capacity and quality of life (QoL). Right ventricular (RV) reserve function may limit exercise capacity and QoL in LVAD patients; however, most patients show normal RV haemodynamics at rest.

Purpose

The aim of this study was to investigate whether RV reserve assessed by the changes of RV function during exercise is correlated with exercise capacity and QoL in patients with LVAD.

Methods

We prospectively examined 20 consecutive LVAD patients who were admitted to our university hospital between June 2020 and November 2021 after excluding those who were unable to perform exercise (n=8). All patients underwent invasive exercise right heart catheterisation with simultaneous echocardiography in the supine position. RV stroke work index (RVSWI) was calculated as 0.0136 × stroke volume index × (mean pulmonary artery pressure [mPAP] − right atrial pressure [RAP]) at rest and during exercise. Exercise capacity and QoL were assessed by 6-minute walk distance (6MWD) and peak oxygen consumption (VO2) in cardiopulmonary exercise testing, and the EuroQol visual analogue scale (EQ-VAS), respectively. The patients were divided into two groups according to the median ΔRVSWI (RVSWI change from rest to peak exercise) of 1.45 (interquartile range [IQR] −0.31 to 8.25) g/m2.

Results

Patients were predominantly male (75%) and the median age was 47 (IQR 38–60) years. Patients with lower ΔRVSWI had significantly higher change on RAP (P=0.019), but significantly lower change on mPAP (P&lt;0.001) compared to those with higher ΔRVSWI. There were no significant differences in age, gender, primary aetiology of heart failure, type of LVAD devices, or echocardiographic parameters including tricuspid annular plane systolic excursion, and RVSWI at rest between the groups. ΔRVSWI during exercise were positively correlated with 6MWD (R=0.69, P&lt;0.01) and peak VO2 (R=0.66, P&lt;0.01) (Figure A). In addition, ΔRVSWI during exercise were positively correlated with the EQ-VAS (R=0.48, P=0.031). On the other hand, there was no significant correlation between RVSWI at rest and 6MWD (R=−0.11, P=0.63) and peak VO2 (R=0.13, P=0.95), and the EQ-VAS (R=0.11, P=0.61). During a median follow-up period of 312 (IQR 176–369) days, adverse events occurred in 3 patients (15%), including 1 death and 2 hospitalisations for major bleeding and right heart failure. Kaplan-Meier analysis revealed that the adverse events more frequently occurred in patients with lower ΔRVSWI compared to those with higher ΔRVSWI (Figure B).

Conclusions

ΔRVSWI was positively correlated with 6MWD, peak VO2 and EQ-VAS irrespective of RV function at rest. Our findings suggest that the assessment of RV reserve function using ΔRVSWI would be useful for risk stratification in patients with LVAD.

Funding Acknowledgement

Type of funding sources: None.

P-039 Male age is associated with sperm DNA integrity: Selection of high DNA integrity sperm by microfluidics sorting is critical to clinical outcomes in older patients

Study question

Does sperm DNA integrity affect clinical outcomes of ICSI?

Summary answer

Use of high DNA integrity sperm selected by microfluidics sperm sorting results in lower miscarriage rates in the patients of 39-years old and more.

What is known already

High sperm DNA damage is associated with decreased normal fertilization, embryo development and pregnancy rates, and an increased miscarriage rate. On the other hand, oocytes from older women have decreased pregnancy rate, and increased miscarriage rate because of possibility of low ability to repair sperm with DNA fragmentation, and dramatical increases of aneuploidy as women age. A microfluidic sperm selection chamber (MSS, ZyMōt™; DxNow) is a device designed to collect sperm with higher chromatin integrity than density gradient centrifugation (DGC).

Study design, size, duration

Sperm analysis was performed by sperm chromatin dispersion (SCD) test and comet assay in the same sample of 15 cases between October 2020 and February 2021. ICSI outcomes by DGC and MSS were compared with blastocyst development, and pregnancy rates in vitrified-thawed single blastocyst transfers cycle for 518 cases between August 2018 and May 2021.

Participants/materials, setting, methods

SCD test was optimized as a rapid procedure, with sperm showing a halo deemed normal, and those without a halo abnormal. Comet assay results were analyzed using CometScore 2.0, with comparison of %Tail DNA. ICSI outcomes were analyzed using multiple logistics regressions of male and female ages.

Main results and the role of chance

We found a positive correlation between male age and sperm DNA fragmentation rates in raw semen using SCD test (r = 0.70) and Comet assay (r = 0.42). Higher DNA integrity sperm could select using MSS than DGC. In this study with ICSI outcomes, 170 of 318 (53.5%) blastocyst transfers resulted in pregnancy, and 49 (28.8%) subsequently miscarried. The data were classified according to less than or more than 39 years old of male age detected by multiple logistics regressions. In patients with ≥39 years of male age, the female age was significantly higher and blastocyst and pregnancy rates were significantly lower, and the miscarriage rate was significantly higher than &lt;39 years of male age. Since sperm DNA fragmentation increased in accordance with male age, we compared MSS and DGC in the patients with male age ≥39 years. There was no significant difference in blastocyst, pregnancy, and miscarriage rates in female age &lt;39 years. While in ≥ 39 years of female age, blastocyst and pregnancy rates in MSS were not significantly different from DGC, but the miscarriage rate in MSS was significantly lower than in DGC (27.3 vs. 57.1%).

Limitations, reasons for caution

The sample size for each study was small. Analysis of sperm DNA fragmentation and samples in ICSI outcomes were not the same. The retrospective nature of ICSI outcomes in this study does not allow controlling of unknown confounders.

Wider implications of the findings

Sperm DNA fragmentation depended on male age affected fertility outcomes. However, when male age is higher, masking the effect of male age by female age. In this study, we found out the improvement of ICSI outcome by using high DNA integrity sperm selected by MSS in both ≥39 years.

Trial registration number

Not applicable

O-080 Impact of age-limit policy change for assisted reproductive technology (ART) subsidy in Japan

Study question

What was the impact on treatment age in Japan after a subsidy policy change that set age limits for assisted reproductive technology (ART) treatment?

Summary answer

The national policy introducing age limits in the subsidy may have promoted ART treatment among younger women.

What is known already

Japan has provided partial subsidies for ART treatment since 2004. To promote treatment at a younger age, the government introduced a subsidy policy in 2016 that set age limits: up to six treatment cycles for women younger than 40 years of age; and up to three cycles for women between 40 and 42 years old. However, two out of 47 prefectures continued to provide subsidies to women aged 43 and older.

Study design, size, duration

We conducted a time series analysis of the utilisation of ART before and after the introduction of age limits, using data from the Japanese national ART registry from 2012 to 2016.

Participants/materials, setting, methods

We described the number of fresh and frozen treatment cycles, comparing the number between 45 prefectures that followed the national policy change (hereafter, prefectures with age limits) and two prefectures that did not (hereafter, prefectures without age limits). Ordinary least squares regression models were used to assess the impact of the policy change by prefecture on the number of ART cycles by women of different ages.

Main results and the role of chance

The overall number of fresh and frozen ART cycles continuously increased in all age groups from 2012 to 2016. Meanwhile, the number of fresh ART cycles among women aged ≤ 36 and 37-39 years in 2016 increased from the previous year by + 4.0% and +1.8% in prefectures with age limits, whereas it decreased in prefectures without age limits: -3.1% and -2.3%, respectively. The number of fresh ART cycles among women aged 40-42 and 43-45 years in prefectures with age limits in 2016 changed by + 1.5% and -0.1%, respectively, whereas it increased considerably in prefectures without age limits by + 9.6% and +65.4%, respectively. Similar changes were shown for the frozen cycles. After controlling for underlying time trends and prefectural characteristics, the policy change significantly increased the number of fresh and frozen ART treatment cycles among women aged ≤ 36 years and decreased the treatment cycles of women aged 40-42 years.

Limitations, reasons for caution

We evaluated the change observed in the year of the policy change and could not assess longer-term trends. Additionally, unobserved factors might have contributed to the change in treatment numbers.

Wider implications of the findings

The introduction of a policy to set an age limit for the partial ART subsidy resulted in a significant increase in treatment even among age groups younger than the boundary groups. The policy change might have conveyed educational messages regarding the benefits of early treatment.

Trial registration number

not applicable

Characterization of the expression of gastrin-releasing peptide and its receptor in the trigeminal and spinal somatosensory systems of Japanese macaque monkeys: Insight into humans

Gastrin-releasing peptide (GRP) and its receptor (GRPR) have been identified as itch mediators in the spinal and trigeminal somatosensory systems in rodents. In primates, there are few reports of GRP/GRPR expression or function in the spinal sensory system and virtually nothing is known in the trigeminal system. The aim of the present study was to characterize GRP and GRPR in the trigeminal and spinal somatosensory system of Japanese macaque monkeys (Macaca fuscata). cDNA encoding GRP was isolated from the macaque dorsal root ganglion (DRG) and exhibited an amino acid sequence that was highly conserved among mammals and especially in primates. Immunohistochemical analysis demonstrated that GRP was expressed mainly in the small-sized trigeminal ganglion and DRG in adult macaque monkeys. Densely stained GRP-immunoreactive (ir) fibers were observed in superficial layers of the spinal trigeminal nucleus caudalis (Sp5C) and the spinal cord. In contrast, GRP-ir fibers were rarely observed in the principal sensory trigeminal nucleus and oral and interpolar divisions of the spinal trigeminal nucleus. cDNA cloning, in situ hybridization, and Western blot revealed substantial expression of GRPR mRNA and GRPR protein in the macaque spinal dorsal horn and Sp5C. Our Western ligand blot and ligand derivative stain for GRPR revealed that GRP directly bound in the macaque Sp5C and spinal dorsal horn as reported in rodents. Finally, GRP-ir fibers were also detected in the human spinal dorsal horn. The spinal and trigeminal itch neural circuits labeled with GRP and GRPR appear to function also in primates.

Association between right ventricular dysfunction and appropriate icd therapy

Funding Acknowledgements

Type of funding sources: None.

Background

Right ventricular fractional area change (RVFAC) as right ventricular function is recently referred as an independent predictor of sudden cardiac death (SCD). The purpose of this study was to evaluate the association of RVFAC and appropriate ICD therapy in order to determine the cut-off value of RVFAC.

Methods

Consecutive patients who underwent initial ICD implantation for any diseases except for non-dilated phase hypertrophic cardiomyopathy and channelopathy were retrospectively enrolled from 2012 to 2018. Primary endpoint was an initial appropriate ICD therapy. Transthoracic echocardiographic parameters before ICD implantation were evaluated by one physician and one echocardiologist to be validated. Right ventricular dimensions and function were also measured to be analyzed.

Results

In total, 172 patients (60.3±13.6 years, 131 males) including 63 ischemic cardiomyopathy were enrolled. Ninety patients received an ICD as a secondary prophylaxis. Mean LVEF and RVFAC were 38.3±14.3% and 35.8±8.82%, respectively. There was little correlation between RVFAC and LVEF (correlation coefficient =0.274). Regarding appropriate ICD therapy events, the best cut-off value of RVFAC was 34.8%. The odds ratio of low RVFAC was 2.731 (95%CI: 1.456-5.121, P=0.00174). Secondary prophylactic cohort with low RVFAC showed highest incidence of appropriate ICD therapy as shown in the figure. In multivariate analysis, only low RVFAC is an independent predictor of appropriate ICD therapy (HR: 3.53, 95%CI:1.78- 6.99, P=0.0003).

Conclusion

Low RVFAC seemed independently associated with increased appropriate ICD therapy.

Negative prognostic implications of non-sustained ventricular tachycardias in patients after prophylactic defibrillator implantation

Funding Acknowledgements

Type of funding sources: None.

Background

Non-sustained ventricular tachycardia (NSVT) is frequent phenomenon in severe heart failure with reduced ejection fraction (HFrEF) patients, and causes any negative impacts on such patients. In the Japanese Circulation Society (JCS) and Japanese Heart Rhythm Society (JHRS) guidelines, NSVT is regarded as a major component of indication for implantable cardioverter defibrillator (ICD) implantation. However, the long-term prognostic significance of NSVT in severe HFrEF is incompletely resolved.

Purpose

The aim of this study is to investigate the relation between prior NSVT episodes and major adverse cardiac events (MACEs) in HFrEF patients with an ICD as primary prophylaxis.

Methods

We retrospectively analyzed our ICD database. Patients underwent primary prophylactic ICD implantation from 2007 to 2018 following ICD recommendation of JCS and JHRS guidelines. Patients met the criteria of receiving optimal medication therapy, symptomatic heart failure (New York Heart Association classification II or greater), and severe cardiac dysfunction (left ventricular ejection fraction (LVEF) is 35% or less). In the case of ischemic cardiomyopathy (ICM), implantation of ICD was done at least 40 days after myocardial infarction and at least 90 days after revascularization. Incidence of NSVT episodes were identified through daily electrocardiogram (ECG), Holter ECG or monitor ECG in the hospital. MACEs were defined as composite outcome of cardiovascular death, heart failure hospitalization, and appropriate ICD therapies.

Results

A total of 148 consecutive patients were enrolled (male, 120 (81%); age, 62.1±11.8 years; LVEF, 23.0±5.86%; left ventricular end-diastolic diameter (LVDd), 67.6±9.26mm; paroxysmal or persistent atrial fibrillation (AF), 38 (26%); NSVT, 113 (76%); use of class III antiarrhythmic drugs, 48 (32%); ICM, 49 (33%); cardiac resynchronization therapy (CRT), 63 (43%)). The median follow-up duration was 58.5 months. As a result of comparison of the Kaplan-Meier curve between NSVT group (n=113) and non-NSVT group (n=35), cardiovascular death, heart failure hospitalization, and appropriate ICD therapy were not statistically different (Figures). Of those, MACEs were occurred to 60 patients (41%). The results of cox-regression analysis showed LVDd (HR: 1.07, 95% CI: 1.03-1.12, p&lt;0.001), AF (HR: 2.88, 95% CI: 1.56-5.31, p&lt;0.001) and ICM (HR: 1.78, 95% CI: 1.00-3.16, p=0.049) were the independent predictors of MACEs, however NSVT was not (Table).

Conclusions

In this Japanese population, the long-term prognosis of severe HFrEF patients is considered to be comparable regardless of prior NSVT episodes. However, the incidence of MACEs in patients with severe HFrEF after ICD implantation was substantially high. ICM, left ventricle size, and atrial fibrillation were the potential risk factors for MACEs as the previous reports showed.

Vasopressin-oxytocin-type signaling is ancient and has a conserved water homeostasis role in euryhaline marine planarians

Vasopressin/oxytocin (VP/OT)-related peptides are essential for mammalian antidiuresis, sociosexual behavior, and reproduction. However, the evolutionary origin of this peptide system is still uncertain. Here, we identify orthologous genes to those for VP/OT in Platyhelminthes, intertidal planarians that have a simple bilaterian body structure but lack a coelom and body-fluid circulatory system. We report a comprehensive characterization of the neuropeptide derived from this VP/OT-type gene, identifying its functional receptor, and name it the "platytocin" system. Our experiments with these euryhaline planarians, living where environmental salinities fluctuate due to evaporation and rainfall, suggest that platytocin functions as an "antidiuretic hormone" and also organizes diverse actions including reproduction and chemosensory-associated behavior. We propose that bilaterians acquired physiological adaptations to amphibious lives by such regulation of the body fluids. This neuropeptide-secreting system clearly became indispensable for life even without the development of a vascular circulatory system or relevant synapses.

Impact of perioperative interruption of antithrombotic therapy on thrombotic and bleeding events in non-cardiac surgery

Funding Acknowledgements

Type of funding sources: None.

Introduction

Antithrombotic therapy including antiplatelet agents and anticoagulants are prescribed for secondary prevention in patients with established cardiovascular disease. Although antithrombotic therapy is often interrupted before non-cardiac surgery with or without perioperative bridging anticoagulation, the impact on thrombotic and bleeding events remains uncertain. 

Purpose

The aim of this study was to clarify the impact of perioperative interruption of anticoagulants on thrombotic and bleeding events in patients with established CVD undergoing elective non-cardiac surgery. 

Methods

A total of 330 patients chronically treated with antithrombotic therapy for secondary prevention underwent elective non-cardiac surgery under general anesthesia, with the complete interruption of antithrombotic agents. The study endpoints included all-cause death, thrombotic events, and major bleeding complications after surgical procedures. 

Results

Of 330 patients, 171 (51.8%) and 159 (48.2%) received antiplatelet agents and anticoagulants perioperatively. Atrial fibrillation (31.8%) and coronary artery disease (20.3%) were the major indications for antithrombotic regimens. Antithrombotic therapy was interrupted from 5 [2, 7] days before the surgery to 4 [2, 7] days postoperatively. Perioperative bridging therapy with unfractionated heparin was employed in 99 (30.0%) patients. During the hospitalization, 3 (0.9%) patients died due to non-cardiovascular causes. Thrombotic events and major bleeding occurred in 2 (0.6%) and 9 (2.7%) patients. Bridging therapy with heparin was non-significantly associated with an increased risk of bleeding events (5.1% vs. 1.7%, p = 0.09). In univariable and multivariable analyses, pre-operative hemoglobin level and operative duration were significantly associated with bleeding complications.

Conclusions

In the present study, complete interruption of antithrombotic therapy resulted in a few thrombotic events with a numerically higher rate of bleeding events in patients undergoing elective non-cardiac surgery. Pre-operative hemoglobin level and operative duration were significantly associated with post-operative bleeding complications.

J waves reaching to equal or more than 2 of 3 LV inferior wall leads may predict the presence of organized myocardial fibrotic or fat change in survivors of ventricular fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

The distribution of J waves and the presence of organized left ventricular (LV) myocardial damage may be related in survivors of ventricular fibrillation (VF).

Purpose

To predict the presence of organized myocardial damage such as fibrotic or fat change on cardiac computed tomography (CT) using the distribution of J waves in survivors of VF.

Methods

We conducted a retrospective analysis of 21 survivors of VF (17 males; mean age, 61 ± 14 years) that were implanted with a cardioverter defibrillator and underwent cardiac CT.

Results

On ECG, 4 patients had atrial fibrillation and 15 had J waves. On CT, 13 patients had organized LV myocardial fibrotic and/or fat change in myocardium. The mean corrected QT interval was 453 ± 30 and 429 ± 48 msec in patients with and without myocardial fibrotic and/or fat change, respectively (P = 0.182). The distribution of J waves was as follows: 5 had J waves in II, III and aVF leads (one had myocardial fibrotic and/or fat change) and 2 had J waves in III lead (one had myocardial fibrotic and/or fat change). One patient each had J waves in V1 lead; V1,2 leads; II, III, aVF and V1-3 leads; I, III, aVF and V1 leads; II, III, aVF, aVL and V1-6 leads; II, III, aVF and V4,5 leads; II, III, aVF and V2-5 leads; and III and aVF leads. The first one did not have myocardial fibrotic and/or fat change and the remaining 6 had myocardial fibrotic and/or fat change. If the J waves reached to ≥1 of 3 LV inferior wall leads (II, III, aVF leads) (N = 13), 10 (77%) had LV myocardial fibrotic and/or fat change. If not (N = 8), 3(38%) had LV myocardial fibrotic and/or fat change (P = 0.071). If the J waves reached ≥2 of 3 LV inferior wall leads (N = 11), 9 (82%) had LV myocardial fibrotic and/or fat change. If not (N = 10), 4 (40%) had LV myocardial fibrotic and/or fat change (P = 0.049). If the J waves reached all three LV inferior wall leads (N = 10), 8 (80%) had LV myocardial fibrotic and/or fat change. If not (N = 11), 5 (46%) had LV myocardial fibrotic and/or fat change (P = 0.104).

Conclusions

In survivors of VF, if the J waves reached ≥2 of 3LV inferior wall leads, the frequency of organized LV myocardial fibrotic and/or fat change was significantly higher than those without. Furthermore, the distribution of J waves and the presence of myocardial fibrotic and/or fat change on CT may predict VF. Abstract Figure. CT fibrosis in VF survivors with HCM

Arrhythmogenic right ventricular cardiomyopathy patients with a markedly enlarged RV compressing LV to left side have an atypical distribution of epsilon waves and elevated plasma BNP

Funding Acknowledgements

Type of funding sources: None.

Background

Epsilon waves on V1-3 leads are specific ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) suggesting RV conduction delay. Four dimensional (4D) cardiac CT visualizes ARVC characteristics, such as fibro-fatty invasion into RV and left ventricular (LV) myocardium (RVM, LVM), an enlarged RV, reduced RV motion, and bulging.

Purpose

We hypothesize that Epsilon waves in V4-6 leads suggest LV invasion in ARVC. Alternatively, extreme RV enlargement may compress the LV and cause clockwise rotation; an enlarged RV may itself cause epsilon waves in V4-6 leads.

Methods

Retrospective analysis of 17 patients (11 males, 57 ± 17 yrs) with suspected ARVC undergoing cardiac CT and ECG, 9 of whom met 2010 ARVC task force criteria.

Results

All 9 patients had epsilon waves on ECG; 5 had fibro-fatty invasion into the LVM. We divided the 9 into 5 groups by CT: 1) markedly enlarged RV compressing the LV to the left side with fibro-fatty changes exclusively in RVM (N = 1); 2) similar findings in both RVM and LVM (N = 2); 3) moderately enlarged RV without compression of the LV to the left side and fibro-fatty changes exclusively in RVM (N = 3); 4) the same in both RVM and LVM (N = 2); 5) severe mitral valve regurgitation, a markedly enlarged LV, and a fibro-fatty change in both RVM and LVM (N = 1). The patient in group (gp) 1 showed epsilon waves in V1-6 leads, patients in gp 2 had epsilon waves in V1-6 (N = 1), and V3-5 (N = 1) leads; patients in gp 3 had epsilon waves in V1-4 (N = 2), and V1-3 (N = 1) leads, patients in gp 4 had epsilon waves in V1-3 (N = 1), and V1, 2 (N = 1) leads; finally, the patient in gp 5 had epsilon waves in V4-6 leads. Plasma brain natriuretic peptide (BNP) levels were significantly greater in patients in gp 1 & 2 than gp 3 & 4 (1255 ± 838 vs 80 ± 52 pg/ml, P = 0.016).

Conclusions

ARVC patients with a markedly enlarged RV compressing the LV to the left side (gp 1,2) had a broad (V1-6) or different range (V3-5) distribution of epsilon waves and significantly elevated plasma BNP independent of fibro-fatty invasion of the LV, different from typical ARVC (gp 3,4). Additionally, structural change due to complicated heart disease, such as valvular disease (gp5), may also influence the distribution of epsilon waves in ARVC. Abstract Figure. CT and ECG in ARVC group 1

Clinical manifestation of coronary pulmonary arterial fistula diagnosed by cardiac computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background

 Coronary pulmonary arterial fistula (CPAF) may cause enlargement of an aneurysm, which may rupture or compress other organs, or occurrence of steal phenomenon of coronary arterial (CA) blood flow. We hypothesize that there are various clinical characteristics of CPAF including patient age at diagnosis, method of diagnosis, observed symptoms, complications, and surgical interventions

Methods

 From a total of &gt;17,000 patients undergoing CT from 2000-2019 in our institute, 11 patients diagnosed as having CPAF were analyzed retrospectively. One was treated surgically prior to analysis, and the remaining 10 (3 males; 56 ± 12 years) were followed for a mean of 52 ± 64 months.

Results

 5 were diagnosed as having CPAF through cardiac CT and 2 were diagnosed by invasive coronary angiograms. One was diagnosed by TTE and another patient was diagnosed by TTE and cardiac CT to differentiate from a mediastinal tumor. 4 had dyspnea, 2 had chest pain, and 1 had palpitation. 5 showed other cardiovascular disease (1 with left ventricular non-compaction, and persistent left superior vena cava; 1 with vascular type Ehlers-Danlos syndrome; 1 with hypertrophic cardiomyopathy; 1 with aortic valve regurgitation (AR); and 1 with vasospastic angina pectoris). The occurrence of steal phenomenon of CA blood flow was diagnosed in 4. CA aneurysm was observed in 5. 2 had abnormal flow from descending aorta to pulmonary arteries through CA. Pulmonary arterial systolic pressure &gt;30 mmHg was observed in 2. During the observed periods, 4 underwent surgical procedure to eliminate CA aneurysm (N = 2), or for significant steal phenomenon of CA blood flow (N = 1). A patient with AR underwent CPAF elimination simultaneously with aortic valve replacement. The mean periods between initial diagnoses and surgical intervention was 27 ± 36 months. The remaining 6 were followed without surgical intervention for a mean of 69 ± 76 months without any cardiac events.

Conclusion

 CPAF was diagnosed at a mean age of 56 years and half were diagnosed incidentally by cardiac CT. Five of the 11 patients (45%) underwent a surgical procedure. Patients with CPAF showed various symptoms due to complicating diseases, anatomical configurations, and outcomes. Abstract Figure. Typical CT images of CPAF

Comparison of sites of wall thickening and abnormal late enhancement on cardiac CT and magnetic resonance imaging with electrocardiography findings in patients with confirmed cardiac amyloidosis

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular (LV) wall thickening and diastolic dysfunction on a transthoracic echocardiogram (TTE) without a high voltage R wave on V5 leads on an ECG leads to a diagnosis of cardiac amyloidosis. A final diagnosis is made by endomyocardial biopsy. However, amyloid sometimes invades the right ventricle (RV), and left (LA) and right (RA) atria, causing ECG changes such as sick sinus syndrome (SSS), arrhythmia, and QRS wave axis deviation.

Purpose

To elucidate the relationship between sites of wall thickening and abnormal late enhancement (LE) on cardiac computed tomography (CT) and magnetic resonance imaging (MRI), suggesting amyloid invasion, with ECG findings in patients with cardiac amyloidosis confirmed by biopsy.

Methods

A total of 26 patients (11 females) with suspected cardiac amyloidosis, who had LV wall thickening by TTE without a high voltage R wave in V5 leads on ECG, underwent cardiac CT. LV wall thickening observed on CT in the early phase led to a late phase acquisition. Five patients (3 females, mean age 73 years) were diagnosed with cardiac amyloidosis: complicated multiple myeloma, 2; senile ATTR (transthyretin) amyloidosis, 1; immunoglobulin light chain (AL) amyloidosis, 1; and transthyretin mutation, 1. Four patients underwent cardiac MRI.

Results

Case 1 had wall thickening in the basal interventricular septum (IVS), LV inferior-posterior wall, LA on CT, abnormal LE in the endocardium in whole LV, RV, and RA on CT, and LE in the endocardium in whole LV, RV, LA, and IVS on MRI. ECG showed SSS (junctional rhythm), left axis QRS wave deviation, no low voltage R wave in limb leads, and a mild LA load. Case 2 had wall thickening in whole LV, RV, LA, and IVS on CT, and unclear (CT) or no (MRI) abnormal LE. ECG revealed SSS (junctional rhythm), a normal QRS axis, no low voltage R wave in limb leads, and no LA load. Case 3 had wall thickening in the LA and basal IVS on CT, abnormal LE in the LA and basal IVS on CT, and LE in the LA only on MRI. ECG revealed atrial tachycardia, a normal QRS axis with low voltage R wave in limb leads, and no LA load. Case 4 had wall thickening in the LA, an RV moderator band on CT, an unclear LE on CT, and LE in whole LV, endocardium in the RV, and whole IVS on MRI. ECG showed a normal sinus rhythm, left axis QRS wave deviation, with low voltage R wave in limb leads, and no LA load. Case 5 had wall thickening in the IVS, LV lateral wall, LV anterior wall, RA, RV outflow tract, and RA appendage, and no abnormal LE on CT (MRI not performed). ECG revealed a normal sinus rhythm, right axis QRS wave deviation, with low voltage R wave in limb leads, and a mild LA load.

Conclusions

In this pilot study of a small number of patients with cardiac amyloidosis, few relationships between sites of wall thickening and abnormal LE on ECG were found. However, a long-term follow-up study with more patients may reveal relationships between such parameters using this methodology. Abstract Figure. Classification by wall thickening on CT

Learning curve of visually-guided laser balloon ablation of paroxysmal atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

The visually-guided laser balloon (VGLB) is a compliant, variable-diameter balloon that delivers laser energy around the pulmonary vein (PV) ostium under real-time endoscopic visualization. However, limited data exist in Japan thus far. Therefore, we determined the safety, efficacy, and learning curve of the VGLB for PV isolation.

Methods

A total of 52 consecutive patients with paroxysmal atrial fibrillation were prospectively enrolled and divided into 3 groups (T1 = 15 patients, T2 = 15 patients, T3 = 22 patients). All patients underwent PV isolation by 2 operators using the VGLB. The operators were experienced in radiofrequency and cryothermal procedures, but not in laser ablations.

Results

Tables show the acute clinical results. Reversible phrenic nerve palsy occurred in 3.8%, with a trend towards a lower complication rate with increasing experience.

Conclusions

The VGLB was safe and effective for PV isolation, even for operators without any previous experience. Procedure time decreased after a learning curve of 30 cases. Abstract Figure. Procedural data and isolation rates

ECG education for first-grade medical students detecting Epsilon and J waves in patients with arrhythmogenic right ventricular cardiomyopathy in comparison with specialists for arrhythmia treatment

Funding Acknowledgements

Type of funding sources: None.

Background

Medical students find Epsilon and J wave diagnoses by electrocardiogram (ECG) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) difficult.

Purpose

To evaluate the inter observer reliability for detecting Epsilon and J wave in patients with ARVC between medical students and specialists for arrhythmia treatment and seek the problem for the ECG education to the students.

Methods

Nine patients (six males, mean age 59 ± 17 years) meeting 2010 ARVC task-force criteria (Circulation. 2010; 121:1533-1541) underwent a retrospective ECG analysis. First-grade medical students undertook ECG studies for 9 months (4 h/week) by a cardiologist who was not a specialist in arrhythmia treatments according to the Japanese Heart Rhythm Society (JHRS). Medical students detected Epsilon and J waves in all nine ECGs. Two JHRS specialists in arrhythmia treatment independently detected Epsilon and J waves; when diagnoses differed, a final diagnosis was made together.

Results

Epsilon waves were detected in five and eight patients by medical students and specialists, respectively. The distribution of Epsilon waves was determined in inferior and right-side precordial leads by students, but in right-side precordial leads only by specialists (Table). J waves were detected in nine and three patients by medical students and specialists, respectively. The J wave distribution was wider for medical students than specialists.

Conclusions

With ECG findings by specialists as the gold standard, even with a substantial education, medical students tended to diagnose Epsilon waves or notches in QRS as J waves. Lecturers need to equip students with additional basic clinical knowledge, such as Epsilon waves are more frequent in right-side precordial leads in ARVC patients. Abstract Figure. CT and ECG in ARVC

Validation of the HFA-PEFF and the H2FPEF scores for the diagnosis of heart failure with preserved ejection fraction in Japanese patients:a report from the Japanese multicentre registry

Background

The standard diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) is based on the following: 1) symptoms of HF, 2) preserved left ventricular (LV) ejection fraction (LVEF, &gt;50%), and 3) presence of LV diastolic dysfunction confirmed by echocardiography or cardiac catheterisation. However, there are limits to the diagnostic accuracy of individual parameters, and what cut-off values should be applied and how they should be combined remain unclear. Diagnostic algorithms for HFpEF such as the HFA-PEFF algorithm and the H2FPEF score have been proposed; however, previous validation studies were conducted in stable chronic HF and did not include an invasive haemodynamic assessment. Thus, the diagnostic accuracy for HFpEF lacked robustness. Moreover, information on their applicability in the Asian population is limited.

Purpose

The aim of this study was to investigate these scores' diagnostic validity for HFpEF in Japanese patients recently hospitalised due to acute decompensated HF.

Methods

We examined patients with HFpEF recently hospitalised with acute decompensated HF whose HFA-PEFF and H2FPEF scores could be calculated at discharge from a nationwide HFpEF-specific multicentre registry (HFpEF group) and control patients who underwent echocardiography to investigate the cause of dyspnoea in our hospital (Non-HFpEF group). We calculated the HFA-PEFF and the H2FPEF scores among the studied population. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were computed to compare the diagnostic accuracy of these scores.

Results

The studied population included 372 consecutive patients (194 HFpEF group and 178 Non-HFpEF group; HFpEF prevalence, 52%). The HFA-PEFF score classified 155 (42%) of all patients into the high likelihood category (5–6 points) and only 19 (5%) into the low likelihood category (0–1 point). A high HFA-PEFF score could diagnose HFpEF with a high specificity of 84% and a positive predictive value (PPV) of 82%, and a low HFA-PEFF score could rule out HFpEF with a high sensitivity of 99% and a negative predictive value (NPV) of 89%. The H2FPEF score classified 86 (23%) of all patients into the high likelihood category (6–9 points) and 84 (23%) into the low likelihood category (0–1 point). HFpEF could be diagnosed with a high H2FPEF score (specificity, 97%; PPV, 94%) or ruled out with a low H2FPEF score (sensitivity, 97%; NPV, 93%). The diagnostic accuracy for the HFA-PEFF and H2FPEF scores was 0.82 (95% confidence interval [CI] 0.78–0.86) and 0.89 (95% CI 0.86–0.93), respectively, by the AUC of the ROC curve (P=0.004) (Figure 1A). In the HFA-PEFF sub-scores, the functional score showed little diagnostic value, while the morphological and biomarker scores showed moderate diagnostic value (Figure 1B).

Conclusions

The H2FPEF score may be more useful than the HFA-PEFF score in diagnosing HFpEF in Japanese patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (JSPS KAKENHI) Figure 1

Relationship of early intensive- or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure

Background

The management of acute decompensated heart failure (ADHF) often requires intensive care. However, the effects of early intensive care unit (ICU)/coronary care unit (CCU) admission on activities of daily living (ADL) in ADHF patients have not been precisely evaluated. Thus, we assessed whether early ICU entry can improve post-discharge ADL performance in these patients.

Methods and results

ADHF patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into ICU/CCU (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where treatment assignment (ICU/CCU admission) is independent of measured baseline confounding factors including ADL at admission. The primary outcome was post-ADL defined according to the Barthel index (BI) at discharge. Secondary outcomes included length of stay (LOS) and total hospitalization cost (expense). Overall, 12,231 patients were eligible, and propensity score matching created 2,985 pairs. After matching, post-ADL was significantly higher in the ICU group (GW 71.5±35.3 vs. ICU 78.2±31.2, P&lt;0.001, difference in mean 6.7 (95% CI 5.1–8.4) points). After matching, LOS was significantly shorter and expenses were significantly higher in the ICU group. Subanalyses showed that patients with low ADL at admission (BI&lt;60) mainly benefited from early ICU/CCU entry.

Conclusions

Early ICU/CCU entry was beneficially associated with post-ADL in patients with emergency ADHF admission. ADL at admission might serve as a useful criterion for ICU admission.

Funding Acknowledgement

Type of funding sources: None.

SPECT-guided myocardial perfusion and metabolic fatty acid planar imaging to assess the severity of the pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension

Background

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) represent right ventricular (RV) enlargement and hypertrophy, which consequently increase the RV myocardial perfusion. Although the main energy source of myocardium is fatty acid, it remains unknown whether myocardial fatty acid metabolism is altered in loaded RV. Herein, we report a novel approach to assess the RV perfusion and fatty acid metabolism, which is called SPECT-guided planar imaging.

Purpose

To evaluate if SPECT-guided myocardial perfusion and metabolic fatty acid planar imaging reflects the severity of the pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension.

Methods

The study groups included 30 patients with CTEPH and 20 healthy controls. In these patients with CTEPH, 15 patients underwent pulmonary thromboendarterectomy (PEA). Mean pulmonary artery pressure (mPAP) by right heart catheterization was obtained in all CTEPH patients. 201Thallium (201Tl) and iodine-123-beta-methyl iodophenyl pentadecanoic acid (123I-BMIPP) planar myocardial imaging was performed in all participants. For the patients undergoing PEA, repetitive SPECT-guided 201Tl and 123I-BMIPP planar imaging was performed one year after the procedure. To assess the RV overload, the planar images were performed in left anterior oblique position, optimized to separate the RV from the left ventricular (LV) using SPECT-guided transverse imaging. We measured the total counts of 201Tl and 123I-BMIPP in both the RV and LV. Moreover, we calculated their relative counts of the RV to LV (abbreviated as HR/HL (Tl) and HR/HL (BMIPP), respectively) to determine the indices of myocardial perfusion and fatty acid metabolism, respectively.

Results

Both HR/HL (Tl) and HR/HL (BMIPP) were elevated in the CTEPH patients compared with control (0.62±0.14 vs. 0.36±0.07, p&lt;0.01 and 0.57±0.14 vs. 0.34±0.06, p&lt;0.01, respectively). In the CTEPH patients, average mPAP was 44.0±9.52 mmHg, which was correlated with HR/HL (Tl) (r=0.675, p&lt;0.001) and HR/HL (BMIPP) (r=0.685, p&lt;0.01). Furthermore, the decrease of average mPAP 1 year after PEA was positively associated with the decrease of HR/HL (Tl) (r=0.646, p&lt;0.01) and HR/HL (BMIPP) (r=0.504, p&lt;0.05) 1 year after PEA.

Conclusions

In patients with CTEPH, RV myocardial perfusion and fatty acid metabolism was upregulated and moderately correlated with mPAP. SPECT-guided 201Tl and 123I-BMIPP planar imaging is a novel and noninvasive imaging modality to assess the severity of PH.

Funding Acknowledgement

Type of funding sources: None.

Prognosis of apical hypertrophic cardiomyopathy in patients with an implantable cardioverter defibrillator

Background

Prophylactic use of implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac death (SCD) is widely spread all over the world in patients with hypertrophic cardiomyopathy (HCM). Apical HCM is a phenotype variant of HCM, with hypertrophy predominantly affecting apex, that was initially described 30 years ago. Apical HCM patients may have different clinical prognosis compared with other subsets of HCM. In previous studies, apical HCM patients seem to have a more benign prognosis than other types of HCM. However, little is known about the long-term outcomes of apical HCM and there are many unclear points. Moreover, there are few reports about the clinical prognosis in apical HCM patients with an ICD.

Objective

The aim of this study is to identify the difference between the prognosis of apical and the other HCM patients with an ICD.

Methods

We retrospectively analyzed the database of our ICD clinic. All subjects had been implanted with an ICD from October 2006 to August 2017. We classified HCM patients into LV outflow tract obstruction (LVOTO) and midventricular obstruction (MVO), apical HCM and other non-obstructive types. We divided all the patients into apical and other types of HCM, and examined their background, incidence of appropriate ICD therapies, hospitalization for heart failure, electrical storm and death.

Results

A total of consecutive 62 Japanese HCM patients with an ICD (follow-up period, 86±25 months; age, 67±14 years; male sex, 85%; left ventricular ejection fraction, 57±12%; LV max wall-thickness, 19±5mm; LV apical aneurysm, 9.7%; HCM Risk-SCD, 4.4±3.0) were enrolled in this study. We classified them into 14 apical HCM and 48 other types of HCM patients. The clinical characteristics and major events of these patients are shown in the Figure. During the follow-up periods, there were no significant differences in the incidence of hospitalization for heart failure, electrical storm and death between the 2 groups (p=0.40; p=0.22; p=0.23). Appropriate therapies occurred in 5 of 14 (36%) patients with apical HCM and 4 of 48 (8.3%) patients with other types of HCM (p=0.022).

Conclusions

Appropriate ICD therapy was more prevalent in patients with apical HCM, compared to patients with other types of HCM. However, the incidences of hospitalization for heart failure, electrical storm and death were not significantly different between two groups.

Funding Acknowledgement

Type of funding sources: None.

Frequency and distribution of J waves in survivors of ventricular fibrillation relationship with presence of myocardial fibrotic and or fat change and coronary arterial stenosis on cardiac CT

Background

The presence and distribution of J waves, the occurrence of ventricular fibrillation (VF), and the presence of left ventricular (LV) myocardial fibrotic or fat change or coronary stenosis may be related.

Purpose

To determine the relationship of frequency and distribution of J waves with presence of myocardial fibrotic or fat change and coronary arterial stenosis on cardiac computed tomography (CT) in survivors of VF.

Methods

We conducted a retrospective analysis of 21 survivors of VF (17 males; mean age, 61±14 years) that were implanted with a cardioverter defibrillator and underwent cardiac CT.

Results

On ECG, four subjects had atrial fibrillation. The mean corrected QT interval was 442±39 msec. On CT, two subjects had significant coronary artery stenosis and 12 had LV myocardial fibrotic and/or fat change. The distribution of J waves were as follows: five subjects had J waves in II, III and aVF leads (three had myocardial fibrotic and/or fat change); and 2 had J waves in III lead (one had myocardial fibrotic and/or fat change). One subject each had J waves in V1 lead; V1, 2 leads; II, III, aVF and V1 leads; II, III, aVF and V1–3 leads; II, III, aVF, aVL and V1–6 leads; II, III, aVF and V1–6 leads; II, III, aVF and V4,5 leads; II, III, aVF and V2–5 leads; and III and aVF leads, respectively. The first two subjects did not have LV myocardial fibrotic and/or fat change and the remaining six subjects had myocardial fibrotic and/or fat change (Figure).

Conclusions

Survivors of VF with organized LV myocardial fibrotic and/or fat change showed more frequent J waves with a wider distribution (reached LV inferior wall leads) than survivors without these changes. Monitoring these characteristics on CT may be useful to predict VF.

Funding Acknowledgement

Type of funding sources: None. CT images of fat in a VF survivorJ waves and fibrotic and/or fat change