Efficacy and Safety of Balloon Pulmonary Angioplasty for Patients With Chronic Thromboembolic Pulmonary Hypertension and Comorbid Chronic Obstructive Pulmonary Disease

Background Balloon pulmonary angioplasty (BPA) is a promising treatment modality for nonoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, BPA for atypical CTEPH with concurrent chronic obstructive pulmonary disease (COPD) remains controversial owing to the risk of exacerbation of ventilation-perfusion mismatch. We aimed to evaluate the efficacy and safety of BPA for CTEPH with moderate or severe COPD. Methods and Results Data from 149 patients with CTEPH, who underwent BPA from March 2011 to June 2021, were retrospectively analyzed. Patients were divided based on COPD comorbidity: the COPD group (n=32, defined as forced expiratory volume in 1 second/forced vital capacity <70% and forced expiratory volume in 1 second <80% predicted) and the non-COPD group (n=101); patients with mild COPD (n=16) were excluded. Hemodynamic and respiratory parameters were compared between the groups. Hemodynamics improved similarly in both groups (reduction in pulmonary vascular resistance): -55.6±29.0% (COPD group) and -58.9±21.4% (non-COPD group); P=nonsignificant. Respiratory function and oxygenation improved in the COPD group (forced expiratory volume in 1 second/forced vital capacity [61.8±7.0% to 66.5±10.2%, P=0.02] and arterial oxygen partial pressure [60.9±10.6 mm Hg to 69.3±13.6 mm Hg, P<0.01]). Higher vital capacity (P=0.024) and higher diffusing capacity for lung carbon monoxide (P=0.028) at baseline were associated with greater improvement in oxygenation in the multivariable linear analysis. Lung injury per BPA session was 1.6% in the COPD group. Conclusions The efficacy and safety of BPA for nonoperable CTEPH in patients with comorbid COPD were similar to those in patients without COPD. Oxygenation and forced expiratory volume in 1 second/forced vital capacity improved in patients with COPD. BPA should be considered in patients with CTEPH with concurrent COPD.

Efficacy and safety of balloon pulmonary angioplasty for patients with chronic thromboembolic pulmonary hypertension comorbid to chronic obstructive pulmonary disease

Background

Balloon pulmonary angioplasty (BPA) would be promising treatment option for non-operable chronic thromboembolic pulmonary hypertension (CTEPH). However, BPA for CTEPH with Chronic obstructive pulmonary disease (COPD) might exacerbate ventilation perfusion mismatch. The aim is to evaluate the efficacy and safety of BPA for CTEPH with moderate or severe COPD.

Method

Data from 149 CTEPH patients were collected retrospectively who underwent BPA from March 2011 to June 2021. Patients were divided according to the comorbidity of COPD: a COPD group (defined as forced expiratory volume in one second (FEV1.0) / forced vital capacity (FVC)&lt;70% and FEV1.0&lt;80% predicted [n=32]) or a non-COPD group [n=101]. Mild COPD patients (n=16) were excluded. Hemodynamics and respiratory parameters were compared.

Results

Hemodynamics improved similarly in both group (percent decrease of pulmonary vascular resistance; −61.1±12.3% in a COPD group, −65.8±11.1% in a non-COPD group, p=N.S). Patients in a COPD group showed improved respiratory function and oxygenation with FEV1.0% from 61.8±7.0% to 66.5±10.2% (p=0.02), and partial pressure of arterial oxygen from 60.9±10.6mmHg to 69.3±13.6mmHg (p&lt;0.01). Higher vital capacity (r2=0.123, p=0.024), higher diffusing capacity for lung carbon monoxide (r2=0.308, p=0.028) at baseline were correlated with larger improvement of oxygenation after BPA in multivariate linear analyses. Lung injury per session was 1.6% in a COPD group.

Conclusion

The efficacy and safety of BPA for non-operable CTEPH with COPD were equivalent to those of patients without COPD. Oxygenation and FEV1.0% also improved in COPD patients. BPA might be considered even though patients comorbid COPD.

Funding Acknowledgement

Type of funding sources: None.

RC time (resistance × compliance) is related to residual symptom after pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension

Background

Right ventricular (RV) afterload is widely assessed by pulmonary vascular resistance (PVR). However, RV afterload is underestimated because PVR does not account for the pulsatile load. The pulsatile load is often evaluated by pulmonary arterial compliance (PAC). The RC (resistance-compliance) time, which is calculated from the product of PVR and PAC, is considered to remain constant under medical therapy. However, little is known on how RC time is affected by invasive therapy in chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to evaluate change of RC time in patients underwent pulmonary endarterectomy (PEA). Furthermore, we investigated the clinical relevance of RC time.

Methods

We reviewed consecutive 50 patients except for death case underwent PEA. Baseline clinical parameters including RC time before performing PEA and follow-up were evaluated. Patients was classified as decrease or non-decrease according to change of RC time. Furthermore, we classified patients into a NYHA I group who had no symptom after treatment and a residual symptom group in order to investigate the relationship of RC time to residual symptoms.

Results

RC time was significantly decreased after PEA (0.54 ± 0.16 to 0.45 ± 0.12 sec, p < 0.001). Residual symptom after PEA of Decrease group were significantly better than that of Non-decrease group in RC time (12 patients, 40% vs. 11 patients, 78.6%, p < 0.02). Furthermore, multivariate analysis revealed that only RC time after PEA was independently associated with residual symptom (OR 1.026, 95% CI 1.005–1.048; p = 0.017).

Conclusions

RC time was decreased after PEA, and might be a possible indicator for predicting PEA success.

Assessment of oxygenation after balloon pulmonary angioplasty for patients with inoperable chronic thromboembolic pulmonary hypertension

BACKGROUND

The efficacy of balloon pulmonary angioplasty (BPA) in patients with inoperable chronic thromboembolic pulmonary hypertension would be promising. However, some patients showed residual dyspnea or symptoms, despite normalized hemodynamics. We aimed to clarify the clinical impact of oxygenation parameters on BPA outcome.

METHOD

Ninety-nine consecutive patients who underwent BPA from September 2011 to December 2019 were enrolled. We evaluated hemodynamics with right heart catheterization, arterial blood gas examination, New York Heart Association functional class (NYHA-FC), respiratory function tests, nocturnal oximetry, and exercise capacity (6-min walk test and cardiopulmonary exercise testing) at baseline and after BPA.

RESULT

Nearly normal hemodynamics was achieved after BPA (mean pulmonary artery pressure (PAP): 37.5 ± 10.0 to 20.6 ± 4.9 mmHg, p < 0.01). Oxygenation slightly improved (partial pressure of arterial oxygen; 61.5 ± 12.3 to 67.7 ± 12.7 mmHg, p < 0.01). Exertional desaturation remained unchanged (-8.1 ± 4.8 to -7.8 ± 5.1, p = 0.59), and this was associated with residual symptom (NYHA-FC ≥ 2) after BPA (OR 0.591, 95% CI 0.416-0.840, p = 0.003) in multivariate regression analyses. Lower vital capacity (r² = 0.03, p = 0.01), higher mean PAP (r² = 0.08, p = 0.02), and higher minute ventilation/carbon dioxide production (VE/VCO₂) slope (r² = 0.18, p < 0.01), the marker of ventilatory inefficiency, were correlated with exertional desaturation after BPA in multivariate linear analyses.

CONCLUSION

Although hemodynamics nearly normalized, oxygenation did not. Moreover, exertional desaturation remained unchanged. This might cause residual symptom after BPA. Residual pulmonary hypertension suggesting incurable arteriopathy, and higher VE/VCO₂ slope suggesting ventilation-perfusion mismatch might be related to exertional desaturation. Domiciliary oxygen therapy should be continued, if necessary.

Evaluation of microvasculopathy using dual-energy computed tomography in patients with chronic thromboembolic pulmonary hypertension

The existence of microvasculopathy in patients with chronic thromboembolic pulmonary hypertension has been suggested. Recently, dual-energy computed tomography has been used to produce a sensitive iodine distribution map in lung fields to indicate microvasculopathy according to poor subpleural perfusion. Our aim was to evaluate the impact of microvasculopathy on pathophysiology in chronic thromboembolic pulmonary hypertension. According to the extent of poor subpleural perfusion, ninety-three interventional treatment-naïve patients were divided into poorly perfused (n = 49) or normally perfused group (n = 44). We assessed cardiopulmonary exercise test, right heart catheterization, and dual-energy computed tomography parameters for quantitative evaluation of lung perfusion of blood volume score. Lung perfusion of blood volume score in normally perfused group was significantly inversely correlated with pulmonary vascular resistance (pulmonary vascular resistance = 6816.1 × lung perfusion of blood volume score^−0.793, R² = 0.225, p < 0.01), but lung perfusion of blood volume score in poorly perfused group was not. Poorly perfused group had higher pulmonary vascular resistance (879 ± 409 dynes-s/cm⁵ vs. 574 ± 279 dynes-s/cm⁵, p < 0.01) and lower lung perfusion of blood volume score (22.1 ± 5.4 vs. 26.4 ± 6.6, p < 0.01) and % diffusing capacity for carbon monoxide divided by the alveolar volume (59.9 ± 15.4% vs. 78.8 ± 14.2%, p < 0.01). Perfusion of blood volume score in the normally perfused group showed an inverse correlation with pulmonary vascular resistance; however, that in poorly perfused group did not. Microvasculopathy might contribute to severe hemodynamics, apart from pulmonary vascular obstruction. In our experience, more than half of treatment-naïve chronic thromboembolic pulmonary hypertension patients have microvasculopathy.

Impact of lipoprotein(a) levels on angiographic severity of femoropopliteal lesions

Background

High lipoprotein(a) [Lp(a)] levels are a risk factor for peripheral artery disease (PAD). However, the association between Lp(a) levels and angiographic severity of PAD has not been systematically studied.

Purpose

The aim of this study was to assess the impact of Lp(a) levels on angiographic severity of femoropopliteal lesions in patients with PAD.

Methods

We retrospectively analyzed a single-center database including 108 patients (74±8 years, 69% male) who underwent endovascular therapy for de novo femoropopliteal lesions and measured Lp(a) levels before therapy between June 2016 and September 2019. Patients were divided into low Lp(a) [LP(a) &lt;30 mg/dL; 77 patients] and high Lp(a) [LP(a) ≥30 mg/dL; 31 patients] groups. Trans-Atlantic Inter-Society Consensus (TASC) II classification, calcification [referring to peripheral arterial calcium scoring system (PACSS) classification] and lesion length were compared between the groups.

Results

Median Lp(a) was 16 (7–31) mg/dL.The prevalence of TASC II class D (13% vs 38%, P&lt;0.01) and severe calcification (PACSS 4) (6% vs 23%, P=0.02) was significantly higher and lesion length was longer (123±88 mm vs 175±102 mm, P&lt;0.01) in the high Lp(a) group than in the low Lp(a) group.(Table and Figure) In multivariate analysis, Lp(a)≥30 was an independent predictor for TASC II class D (HR=3.67, P=0.02) and PACSS 4 (HR=4.97, P=0.02) prevalence.

Conclusion

Lp(a) was associated with angiographic severity of femoropopliteal lesions in patients with PAD.

Comparison of angiographic severity

Funding Acknowledgement

Type of funding source: None

The role of balloon pulmonary angioplasty and pulmonary endarterectomy: Is chronic thromboembolic pulmonary hypertension still a life-threatening disease?

BACKGROUND

The management of non-operable chronic thromboembolic pulmonary hypertension (CTEPH) has evolved with the availability of balloon pulmonary angioplasty (BPA) and pulmonary vasodilators. We launched the BPA program in 2011. The aim was to analyze the survival and treatment efficacy of our CTEPH treatment program in the modern management era.

METHODS AND RESULTS

We retrospectively reviewed data from 143 consecutive CTEPH patients diagnosed from January 2011 (i.e. after the availability of BPA) to December 2019. Of forty-one patients who underwent pulmonary endarterectomy (PEA), 25 underwent additional BPA (Combination group) and the others were treated with only PEA (PEA group). Ninety patients underwent BPA (BPA group). The remaining 12 patients did not undergo any interventional treatments. The 1- and 5-year survival rates of operated patients (n = 41) were 97.4% and 90.0%, compared to 96.9% and 86.9% in not-operated patients (n = 102), respectively (p = 0.579). There was no mortality in the Combination group. Mean pulmonary artery pressure after treatments in the PEA only, Combination, and BPA only groups was 20.5 ± 6.7, 17.9 ± 4.9, and 20.7 ± 4.6 mmHg, respectively (p = 0.067, one-way ANOVA). Percent decrease of pulmonary vascular resistance in each treatment groups was -73.7 ± 11.3%, -74.3 ± 11.8%, and - 54.9 ± 22.5%, respectively (p < 0.01, one-way ANOVA).

CONCLUSION

There was no significant difference in long-term survival between operated and not-operated CTEPH. Moreover, the Combination approach might have the potential to introduce notable improvements in the prognosis of CTEPH. BPA and PEA appear to be mutually complementary therapies in the modern management era.

Open-Label Multicenter Registry on the Outcomes of In-Stent Restenosis Treated by Balloon Angioplasty with Optical Frequency Domain Imaging in the Superficial Femoral Artery (ISLAND-SFA Study)

Objectives: Balloon angioplasty for in-stent restenosis (ISR) in the superficial femoral artery (SFA) has a high recurrent restenosis rate; however, its mechanism has not been fully and precisely evaluated using high-resolution intravascular imaging. Thus, we aimed to evaluate the relationship between vascular features obtained by optical frequency domain imaging (OFDI) and recurrent restenosis at 6 months. Methods: This was a prospective multicenter single-arm study. OFDI was performed before and after balloon angioplasty, and vascular features were assessed. A multi-layered ISR pattern detected by OFDI was defined as several signal-poor appearances with a high-signal band adjacent to the luminal surface. The primary outcome was defined as recurrent restenosis 6 months after balloon angioplasty. Results: Given that this study was terminated early, only 18 patients completed the 6-month follow-up; of these, 8 developed restenosis. Recurrent restenosis at 6 months tended to be related to a multi-layered ISR pattern (odds ratio (OR), 6.67; 95% confidence interval (CI), 0.81-54.96; p=0.078) and the minimum lumen area (MLA) after balloon angioplasty (OR, 0.71; 95%CI, 0.48-1.04; p=0.077). Conclusion: A multi-layered ISR pattern and MLA after balloon angioplasty detected by OFDI might be risk factors for recurrent ISR in the SFA.

Open-label multicenter registry on the outcomes of peripheral arterial disease treated by balloon angioplasty with optical frequency domain imaging in superficial femoral artery and popliteal artery (OCEAN-SFA study)

Although balloon angioplasty for femoropopliteal artery lesions has been associated with restenosis rates of up to 60% at 12 months, the mechanism of restenosis has not been fully evaluated. The aim of this study was to evaluate the relationship between the vascular features observed on optical frequency domain imaging (OFDI) before and after balloon angioplasty of femoropopliteal artery lesions, and restenosis at 6 months. This study was a prospective multicenter single arm study. OFDI was performed before and after balloon angioplasty and plaque characteristics and vascular features, along with de novo lesions, were assessed. The primary outcome was the presence or absence of restenosis 6 months after balloon angioplasty. Residual platelet reactivity was assessed according to VerifyNow platelet reactivity units (PRUs). The number of patients completing 6 months of follow-up was 47, of which 14 had developed restenosis. Maximum thickness of the dissection flap (odds ratio (OR) 2.71; 95% confidence interval [0.9-8.0]; p = 0.071) and lesion length were identified as risk factors for restenosis (OR 1.015; 95% confidence interval [0.001-0.029]; p = 0.039). The mean PRU at the time of treatment in patients with restenosis was significantly higher than in those without restenosis (286.3 ± 82.6 vs. 208.5 ± 03.6, p = 0.026). Long lesions and major dissection on OFDI after balloon angioplasty for femoropopliteal artery lesions increase restenosis at 6 months. In addition, high residual platelet reactivity at the time of EVT may also be a risk factor for restenosis.Clinical Trial Registration Number UMIN000021120.

P937Impact of left ventricular diastolic dysfunction on long-term outcome in patients with lower extremity artery disease

Background

Left ventricular (LV) systolic dysfunction and heart failure (HF) in patients with lower extremity artery disease (LEAD) is associated with an increased risk for adverse events. However, relationship between long-term outcome in patient with LEAD and LV diastolic dysfunction remains unclear.

Purpose

The aim of this study was to assess the impact of LV diastolic dysfunction on long-term outcome in patients with LEAD.

Methods

Two hundred patients (male 66%, mean age 76±9 years) with preserved LV systolic function assessed by echocardiography (ejection fraction ≥50%) were enrolled from a single-center database between January 2013 to May 2015. Baseline LEAD was identified by ABI <0.9 or history of lower extremity revascularization. Diagnosis of LV diastolic dysfunction was based on the ASE/EACVI guidelines. The 3-year cumulative incidence of primary endpoint compared between LEAD patients with LV diastolic dysfunction than those without. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke and hospitalization for HF during 3 years follow-up. Multivariate analysis was performed to determine whether LV diastolic dysfunction was independently associated with the primary endpoint.

Results

LV diastolic dysfunction was identified in 31%. The mean observation period was 32±21 months. The primary endpoint occurred more frequently in patients with LV diastolic dysfunction than those without at 3 years (30% vs 16%, P=0.02). There were no significant differences between 2 groups in the myocardial infarction (3% vs 3%, P=0.73) and stroke (3% vs 3%, P=0.55). Cardiovascular death (19% vs 7%, P=0.01) and hospitalization for HF (19% vs 7%, P=0.01) were significantly higher in patients with LV diastolic dysfunction. In multivariate analysis, LV diastolic dysfunction was an independent predictor for primary endpoint (HR=2.28, 95% CI 1.10–4.73, P=0.02) (Table)

Predictor for primary endpoint Factors Univariate model Multivariate model Hazard ratio [95% CI] P value Hazard ratio [95% CI] P value Age 1.03 [0.98–1.08] 0.24 1.03 [0.98–1.08] 0.22 Chronic kidney disease 1.53 [0.77–3.07] 0.23 1.25 [0.60–2.58] 0.55 Coronary artery disease 1.08 [0.53–2.18] 0.84 1.18 [0.56–2.50] 0.65 Cerebrovascular disease 1.93 [0.74–5.02] 0.17 2.28 [0.86–6.05] 0.10 Critical limb ischemia 3.75 [1.68–8.37] <0.01 3.72 [0.56–2.50] <0.01 LV diastolic dysfunction 2.37 [1.18–4.74] 0.02 2.28 [1.10–4.73] 0.03

Conclusions

LV diastolic dysfunction increased the risk for adverse events in patients with LEAD.

Acknowledgement/Funding

None

P3644Plaque progression from normal vessel wall to fibroatheroma: lessons from over 5-year follow-up optical coherence tomography study

Background

Progression of atherosclerosis is a non-uniform process characterized by coexistence of normal vessel wall (NVW) and advanced fibroatheroma within the same cross-section (Figure). Plaque progression from NVW to fibroatheroma usually takes years, that has never been investigated in human.

Purpose

To investigate the incidence and related factors associated with atherosclerotic progression from NVW to fibroatheroma using long-term serial optical coherence tomography (OCT) follow-up data over 5 years.

Methods

We enrolled 47 vessels in 30 patients who had undergone serial OCT imaging over 5 years (average: 6.8 years). Baseline and follow-up OCT images were matched for longitudinal and circumferential location and OCT cross-sections that had NVW >30 degrees were enrolled. NVW was defined as vessel wall having OCT-detectable three-layer structure with intimal thickening ≤300μm. Cross-sections were diagnosed as +Progression when NVW in the cross-section reduced by >30 degrees during >5-year follow-up.

Results

In the present study, atherogenic progression from NVW to fibroatheroma was observed only in 37.2% of the enrolled cross-sections. On the other hand, despite an average long-term follow-up period of 6.8 years, the extent of NVW was maintained in 62.8% of cross-sections. The incidence of microchannel in adjacent fibroatheroma within the same cross-section (23.6% vs. 13.1%, p=0.023), eccentric plaque distribution (21.7% vs. 11.4%, p=0.019), and concave shape (6.6% vs. 0%, p=0.001) at baseline was significantly higher in cross-sections with +Progression than those without Progression. Average intimal thickness of NVW (187.2±64.9μm vs. 170.7±68.6μm; p=0.048) at baseline was significantly thicker in cross-sections with +Progression than those without. Multivariate analysis demonstrated that the presence of microchannel, eccentric plaque distribution and thicker average intimal thickness of NVW at baseline were independently associated with plaque progression during the follow-up.

Atheroma progression

Conclusion

The presence of microchannel in adjacent fibroatheroma, eccentric plaque distribution, and thicker intimal thickening of NVW were potentially associated with plaque progression from NVW to fibroatheroma.

P5022Dual-energy CT was effective to evaluate of microvasculopathy in chronic thromboembolic pulmonary hypertension

Background

The existence of microvasculopathy in patients with chronic thromboembolic pulmonary hypertension (CTEPH) had been suggested. However, the impact of microvasculopathy for pathophysiology had been unknown. Recently dual-energy CT (DECT) can produce a sensitive iodine distribution map as blood perfusion in lung fields to quantify lung perfusion, also can suggest the existence of microvasculopathy according to poor subpleural perfusion which was published previously.

Methods

We retrospectively reviewed poor subpleural perfusion (defined as subpleural spaces either not or minimally perfused in all segments) and hemodynamics of 83 treatment-naïve CTEPH patients who underwent DECT from February 2014 to Jan 2019. Patients were divided according to poor subpleural perfusion: a microvasculopathy group (n=44) or a non-microvasculopathy group (n=39).

We assessed cardiopulmonary exercise test, right heart catheterization and DECT parameters as quantitative evaluation of pulmonary blood volume (PBV). PBV was calculated as the average of entire lung iodine density.

Results

PBV value in non-microvasculopathy group showed significant inverse correlation with pulmonary vascular resistance (PVR) (y = 14236 x-1.028 r=−0.530, p<0.01).

PBV, SvO2, and %DLCO/VA were significantly lower (22.0 vs. 26.4, p<0.01, 61.3 vs. 66.0, p<0.01, and 59.2 vs 75.9 p<0.01), and systolic pulmonary arterial pressure, PVR, VE/VCO2 slope, BNP were higher (69.3 vs 60.6 p=0.04, 834 vs 586 p<0.01, 45.5 vs. 37.8, p=0.02, and 440 vs 122 p=0.04) in microvasculopathy group, while the other parameters were similar between the two groups.

Multivariate analysis revealed that %DLCO/VA was the only predictor of microvasculopathy (OR,0.895 [95% CI, 0.835 - 0.960]; P<0.01).

Conclusion

Pulmonary blood flow of patients in non-micorvasculopathy group showed inverse correlation with PVR. DECT was effective to assess the microvasculopathy in CTEPH. In our experience, less than 60% of non-operable CTEPH patients have microvasculopathy.

P6468Balloon pulmonary angioplasty for patients with symptomatic chronic thromboembolic disease without pulmonary hypertension

Background

Chronic thromboembolic disease (CTED) is characterised by thromboembolic stenosis and obstruction of pulmonary arteries without pulmonary hypertension. The treatment approach for symptomatic patients with CTED is still controversial. It has been reported the efficacy of surgical endarterectomy for patients with CTED, however that of balloon pulmonary angioplasty (BPA) for non-operable CTED has not been well established.

Method

We started aggressive BPA protocol for non-operable CTED patients who suffered from symptom with NYHA class II, III, and IV or limitation of exercise in spite of mean pulmonary artery pressure (mPAP) <25 mmHg since February 2014. We evaluated subjective symptoms, hemodynamic parameters by right heart catheter, and exercise capacity by cardiopulmonary exercise test at baseline and after the last BPA session.

Results

Twenty-three patients with CTED (68.7±10.5 years-old, 7 male) had undergone BPA. In these, 7 patients had received pulmonary vasodilators previously. After 2.9±1.3 sessions of BPA, Further improvement was observed in hemodynamics such as mPAP (21.6±2.3 to 17.1±2.6 mmHg, p<0.01), pulmonary vascular resistance (278±80 to 198±63 dyne/s/cm–5, p<0.01), which were accompanied with improved peak VO2 (14.6±4.4 to 17.4±4.2 ml/min/kg, p<0.01), VE/VCO2 slope (39.6±14.6 to 30.2±6.0, p=0.01), and functional class (I/II/III/IV; 0/10/12/1 to 9/12/2/0, p<0.01) (Table). All patients were tolerable, and no severe complication regarding to BPA.

Table 1 Variables Baseline After BPA (3 month) P value NYHA class (I / II / III / IV) 0 / 10 / 12 / 1 9 / 12 / 2 / 0 <0.01 Mean PAP (mmHg) 21.6±2.3 17.1±2.6 <0.01 PVR (dyne/sec/cm–5) 278±80 198±63 <0.01 6 MWD (m) 354±93 382±96 0.09 Peak VO2 (ml/min/kg) 14.6±4.4 17.4±4.2 <0.01

Conclusion

BPA may have the potential to achieve further improvement of exercise capacity and symptoms in CTED patients with acceptable risk, therefore BPA should be considered as a treatment option for symptomatic patients with non-operable CTED.

P5508Impact of CD14++CD16+ monocytes on coronary plaque vulnerability assessed by optical coherence tomography in coronary artery disease patients

Background

Diabetes mellitus has been known as an important factor of coronary artery disease (CAD) progression despite of widespread with lipid-lowering therapy. Although we have reported that large glucose fluctuation is associated with the development of cardiovascular disease in both diabetes mellitus (DM) and non-DM patients, the underlying mechanisms remain unclear.

Monocytes play a key role for atherosclerotic plaque formation. Monocytes in human peripheral blood are divided into three subsets: CD14++CD16− monocytes, CD14++CD16+ monocytes, and CD14+CD16++ monocytes. The CD14++CD16+ monocyte subset has recently received attention because it is reported to be associated with future cardiovascular events such as acute myocardial infarction. However, their impact on coronary plaque vulnerability in coronary artery disease (CAD) patients with or without DM remains unclear.

Purpose

The aim of this study was to investigate the impact of CD14++CD16+ monocyte levels on coronary plaque vulnerability and glucose fluctuation in stable CAD patients with well-regulated lipid levels.

Methods

This prospective observational study included 50 consecutive patients with CAD (DM [n=22], Non-DM [n=28]), receiving lipid-lowering therapy and undergoing coronary angiography and optical coherence tomography (OCT). Patients were divided into 3 tertiles according to the CD14++CD16+ monocyte percentages assessed by flow cytometry. Standard OCT parameters including lipid arc, lipid length, fibrous cap thickness (FCT) on lipid rich plaque, were assessed for 97 angiographically intermediate lesions (diameter stenosis: 30–70%). The presence of thin-cap fibroatheroma (TCFA), defined as a thin fibrous cap (<65μm) overlying a lipid-rich plaque (>90°), was also assessed. Daily glucose fluctuation assessed by using continuous glucose monitoring system was analyzed by measuring the mean amplitude of glycemic excursion (MAGE).

Results

CD14++CD16+ monocytes negatively correlated with FCT on lipid rich plaque (r=0.508, p<0.01) (Figure. 1). The presence of thin-cap fibroatheroma (TCFA) was increased stepwise according to the tertile of CD14++CD16+ monocytes (0 [tertile 1] vs. 5 [tertile 2] vs. 10 [tertile 3], p<0.01). CD14++CD16+ monocytes were a significant determinant of TCFA (OR 1.279, p=0.001). Although CD14++CD16+ monocytes were not significantly correlated with MAGE in DM patients (r=0.259, p=0.244), a significant relationship was found between CD14++CD16+ monocytes and MAGE in non-DM patients (r=0.477, p=0.018) (Figure 2).

Conclusions

CD14++CD16+ monocytes were associated with coronary plaque vulnerability in CAD patients with well-regulated lipid levels both in DM and non-DM patients. Cross-talk between glucose fluctuation and CD14++CD16+ monocytes may enhance plaque vulnerability, particularly in non-DM patients. CD14++CD16+ monocytes could be a possible therapeutic target for coronary plaque stabilization.

P4591Impact of extent of non-culprit lesions on one-year outcomes in patients with acute myocardial infarction

Background

Presence of severe stenosis in non-infarct related arteries, i.e. multi-vessel disease (MVD), is associated with poor outcomes after acute myocardial infarction (AMI). However, impact of mild to moderate stenosis in non-culprit lesions remains unclear.Gensini score is an angiographic application grading the extent of coronary artery lesions including mild to moderate stenosis.

Purpose

To evaluate whether the extent of non-culprit lesion is related to one-year outcomes after AMI.

Methods

This study consisted of consecutive 168 patients who underwent primary percutaneous coronary intervention (PPCI) for AMI between 2015 and 2017. Patients with coronary bypass grafts were excluded from the analysis. To assess the extent of non-culprit lesions, we used “non-culprit Gensini score”, which is calculated by excluding score of the culprit lesion from the original Gensini score. Patients were divided into 2 groups by the median ofnon-culprit Gensini score: low score (0–14, n=84) and high score (>15, n=84). Major adverse cardiac events (MACE) included all cause of deaths, non-fatal MI, stroke and ischemia driven coronary revascularization during one-year follow-up period.

Results

MVDwas more frequent in patients with high score than those in those with low score (90% vs 25%, P<0.05). Kaplan-Mayer curves of patients with and without MVD are shown in left figure, and curves of patients with low score and those with high score are shown in right figure. Multivariable analysis showed that high score was an independent predictor of one-year MACE (HR 5.28, 95% CI 1.93–14.9, P<0.05), but MVD was not (HR 0.56, 95% CI 0.23–1.54, P=0.25) (Table).

Multivariable analyses Univariable analyses Multivariable analyses HR (95% CI) P-value HR (95% CI) P-value Age 1.03 (1.01, 1.06) <0.05 1.15 (0.99, 1.05) 0.31 eGFR (<45ml/min/1.73m2) 2.95 (1.59, 5.38) <0.05 2.35 (1.26, 4.35) <0.05 Multi-vessel disease 1.84 (1.01, 3.55) <0.05 0.56 (0.23, 1.54) 0.25 Non-culprit-Gensini score (>15) 3.37 (1.79, 6.78) <0.05 5.28 (1.93, 14.9) <0.05 HR = hazard ratio; CI = confidence interval; eGFR = estimated glomerular filtration rate.

Kaplan-Meier curves

Conclusion

These findings suggested that extent of mild to moderate stenosis in non-culprit lesions might affect the prognosis after AMI in patients undergoing PPCI. Non-culprit Gensini score may be useful to predict outcomes of patients with AMI.

Acknowledgement/Funding

None

Impaired Cholesterol-Uptake Capacity of HDL Might Promote Target-Lesion Revascularization by Inducing Neoatherosclerosis After Stent Implantation

Background We evaluated the importance of high-density lipoprotein (HDL) functionality for target-lesion revascularization in patients treated with coronary stents using a rapid cell-free assay system to evaluate the functional capacity of HDL to accept additional cholesterol (cholesterol-uptake capacity; CUC). Methods and Results From an optical coherence tomography (OCT) registry of patients treated with coronary stents, 207 patients were enrolled and their HDL was functionally evaluated by measuring the CUC. Follow-up OCT was performed (median duration, 24.5 months after stenting) to evaluate the presence of neoatherosclerosis. Clinical follow-up was performed to assess target-lesion revascularization for a median duration of 42.3 months after stent implantation. Neoatherosclerosis was identified in 37 patients (17.9%). Multivariate logistic regression analysis revealed that a decreased CUC was independently associated with neoatherosclerosis (odds ratio, 0.799; P<0.001). The CUC showed a significant inverse correlation with incidence of target-lesion revascularization (odds ratio, 0.887; P=0.003) and with lipid accumulation inside stents, suggesting that neoatherosclerosis contributes to the association between CUC and target-lesion revascularization. Conclusions Impaired HDL functionality, detected as decreased CUC, might lead to future stent failure by provoking atherogenic changes of the neointima within stents. Both quantitative and qualitative assessments of HDL might enable the improved prediction of clinical outcomes after stent implantation.

Pulmonary Endarterectomy and Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension - Similar Effects on Health-Related Quality of Life

Background: While hemodynamics and exercise capacity in patients with chronic thromboembolic pulmonary hypertension (CTEPH) can be improved by invasive therapy such as pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA), there has been little data on the health-related quality of life (HRQOL) in such patients. Methods and Results: This single-center and observational study compared the impact of invasive therapy on HRQOL. We utilized the Medical Outcome Study 36-Item Short Health Survey (SF-36) to measure HRQOL and compared HRQOL changes after PEA and BPA. A total of 48 patients were diagnosed with CTEPH. Of these, 39 patients completed questionnaires before and after invasive therapy. The PEA group (n=15) and the BPA group (n=24) had similar improvements in clinical parameters. With regard to HRQOL score, both groups had fairly low scores in physical functioning (PF), role physical (RP), general health (GH), social functioning (SF), role emotional (RE), and physical component summary (PCS) at baseline. PF, GH, vitality (VT), mental health (MH), and PCS had significant improvements in the PEA group while PCS and all subscales except for bodily pain (BP) had significant improvements in the BPA group. Furthermore, changes between baseline and follow-up were not significantly different between the 2 groups. Conclusions: BPA for patients who are ineligible for PEA can recover HRQOL to a similar level to that achieved by PEA.

Impact of dual antiplatelet therapy with adjusted-dose prasugrel on mid-term vascular response in patients undergoing elective percutaneous coronary intervention with everolimus-eluting stents

The impact of dual antiplatelet therapy (DAPT) with adjusted-dose (3.75 mg/day) prasugrel for Japanese patients has not been fully investigated in terms of local arterial healing following the elective percutaneous coronary intervention (PCI). The ROUTE-01 elective study was a prospective, 12-center and single-arm registry that enrolled 123 patients who underwent elective PCI with everolimus-eluting stents (EESs) under DAPT with a combination of adjusted-dose prasugrel and aspirin. Serial optical coherence tomography (OCT) was performed at the index PCI and 9-month follow-up to assess the relationship between in-stent thorombus (IST) and residual platelet reactivity measuring platelet reactivity unit (PRU). The patients were classified as extensive, intermediate, and poor metabolizers by cytochrome P450 2C19 (CYP2C19) loss-of-function polymorphisms. The prevalence of IST was 9.0% by 9-month OCT, with no difference amongst the three groups (p = 0.886). The incidences of malapposed and uncovered struts were not different among the groups. PRU was not statistically different among the groups. In multivariate logistic regression analysis, the independent predictor for IST on 9-month OCT was irregular protrusion (odds ratio = 8.952, p = 0.037) on post-PCI OCT, not CYP2C19 loss-of-function polymorphisms. An adequate anti-thrombotic effect with an acceptable incidence of IST was observed irrespective of CYP2C19 loss-of-function polymorphisms. Our data suggests that adjusted-dose prasugrel and aspirin is a feasible treatment option in Japanese patients treated with EESs in elective PCI.

Acute Pulmonary Hypertension Crisis after Adalimumab Reduction in Rheumatoid Vasculitis

Rheumatoid vasculitis is a rare etiology for pulmonary hypertension (PH) in patients with connective tissue disease. We encountered a case of acute PH crisis in a case with rheumatoid vasculitis eight months after undergoing adalimumab reduction. Since no repetition of arthralgia occurred after the adalimumab reduction, we decided to not increase the dose of adalimumab. However, hemodynamic collapse thereafter developed and even though steroid pulse therapy was administered, the patient nevertheless died. The autopsy showed clusters of acute and chronic inflammation around the remodeled pulmonary arteries along with micro-thrombi in the vessel lumen. We should consider the possibility of critical worsening of PH as a phenotype of vasculitis related to immunosuppressive therapy reduction.

Sequential Hybrid Therapy With Pulmonary Endarterectomy and Additional Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

Background

Residual symptoms after pulmonary endarterectomy (PEA) remain as the clinical issues to be solved. Additional balloon pulmonary angioplasty (BPA) after PEA showed its efficacy with symptoms in a case series, although long‐term spontaneous recovery of exercise ability after PEA was also reported. However, no studies have validated the clinical efficacy of additional BPA by directly comparing PEA with and without BPA. The aim of this study was to retrospectively evaluate the efficacy of additional BPA as a sequential hybrid therapy for chronic thromboembolic pulmonary hypertension after PEA.

Methods and Results

Among 44 patients with chronic thromboembolic pulmonary hypertension, 20 patients had residual symptoms after PEA. Of those, 10 patients underwent additional BPA (hybrid group) and were compared with the other 10 patients, who were followed up without BPA (PEA group). The period from PEA to additional BPA was 7.3±2.3 months. In hybrid group, mean pulmonary arterial pressure was significantly improved by PEA (40.6±1.8 to 26.9±3.1 mm Hg, P=0.001) and improved further (to 16.7±1.8 mm Hg, P=0.002) with additional BPA, which resulted in remarkable improvement in World Health Organization (WHO) functional class (pre‐ to post‐BPA: class I/II/III/IV, 0/5/4/1 to 7/3/0/0; P<0.001). Compared with the PEA group at follow‐up, the hybrid group achieved better mean pulmonary arterial pressure (18.7±1.7 versus 30.2±3.2 mm Hg, P=0.008), WHO functional class (class I/II/III/IV, 7/3/0/0 versus 0/8/2/0; P=0.001), and 6‐minute walking distance (429±38 versus 319±22 m, P=0.028).

Conclusions

A sequential hybrid strategy improved residual symptoms and exercise capacity compared with single‐PEA therapy.

The optimization of iloprost inhalation under moderate flow of oxygen therapy in severe pulmonary arterial hypertension

Inhaled iloprost efficiently improves pulmonary hemodynamics, exercise capacity, and quality of life in patients with pulmonary arterial hypertension (PAH). However, the process of inhalation is laborious for patients suffering from resting dyspnea. We describe a 75-year-old man with idiopathic PAH and a low gas transfer. Investigations excluded significant parenchymal lung disease and airflow obstruction (presuming FEV1/FVC ration > 70%). The patient struggled to complete iloprost inhalation due to severe dyspnea and hypoxemia. As such, we optimized the methods of oxygen supply from the nasal cannula to the trans-inhalator during the inhalation. We successfully shortened the inhalation duration that effectively reduced the laborious efforts required of patients. We also recorded pulmonary hemodynamics during inhalation of nebulized iloprost. This revealed significant hemodynamic improvement immediately following inhalation but hemodynamics returned to baseline within 2 hours. We hope that this optimization will enable patients with severe PAH to undergo iloprost inhalation.

Successful Pulmonary Artery Embolization for the Management of Hemoptysis in a Patient with Eisenmenger Syndrome Caused by Patent Ductus Arteriosus

The patient was a 19-year-old woman who was diagnosed with patent ductus arteriosus complicating Eisenmenger syndrome at a previous medical institution. She was referred to our hospital and arranged for lung transplantation. She developed hemoptysis after the introduction of i.v. epoprostenol, which was administered as a bridging treatment while the patient awaited lung transplantation. She continued to suffer from recurrent hemoptysis, even after switching from i.v. epoprostenol to i.v. treprostinil. Angiography of the systemic and pulmonary arteries revealed the vessel responsible for the recurrent hemoptysis and pulmonary artery embolization was successfully performed. It is essential to identify the culprit vessel and physicians must not hesitate in performing embolization when patients develop lethal hemoptysis.

Upfront triple combination therapy-induced pulmonary edema in a case of pulmonary arterial hypertension associated with Sjogren's syndrome

Clinical efficacy of combination therapy using vasodilators for pulmonary arterial hypertension (PAH) is well established. However, information on its safety are limited. We experienced a case of primary Sjogren's syndrome associated with PAH where the patient developed pulmonary edema immediately after the introduction of upfront triple combination therapy. Although the combination therapy successfully stabilized her pre-shock state, multiple ground glass opacities (GGO) emerged. We aborted the dose escalation of epoprostenol and initiated continuous furosemide infusion and noninvasive positive pressure ventilation (NPPV), but this did not prevent an exacerbation of pulmonary edema. Chest computed tomography showing diffuse alveolar infiltrates without inter-lobular septal thickening suggests the pulmonary edema was unlikely due to cardiogenic pulmonary edema and pulmonary venous occlusive disease. Acute respiratory distress syndrome was also denied from no remarkable inflammatory sign and negative results of drug-induced lymphocyte stimulation tests (DLST). We diagnosed the etiological mechanism as pulmonary vasodilator-induced trans-capillary fluid leakage. Following steroid pulse therapy dramatically improved GGO. We realized that overmuch dose escalation of epoprostenol on the top of dual upfront combination poses the risk of pulmonary edema. Steroid pulse therapy might be effective in cases of vasodilator-induced pulmonary edema in Sjogren's syndrome associated with PAH.

The importance of catheter stability evaluated by Visitag(TM) during pulmonary vein isolation

BACKGROUND

The recurrence rates of atrial fibrillation (Af) after ablation are still high, and repeat procedures are required in these patients. The main reason for Af recurrence is the recovery of the conduction between the pulmonary veins and left atrium. The importance of catheter stability during the pulmonary vein isolation (PVI) is not well studied.

PURPOSE

The purpose of this study was to evaluate the contact force (CF), stable ablation time, and power during conduction blocking lesion formation for PVI.

METHODS

Thirty-two consecutive drug-refractory Af patients who underwent an initial PVI using CARTO 3 and Visitag were included. The CF, ablation time, force time integral (FTI), and ablation power were recorded by Visitag. Residual conduction gap points requiring touch-up ablation after an encircling linear ablation (R point), spontaneous reconnection points (S point), and dormant conduction points (D point) were considered as non-conduction blocking lesion points. Each ablation parameter for the non-conduction blocking lesion points was compared with the other lesion points.

RESULTS

Twenty-one points in 16 patients were considered non-conduction blocking lesions. Ten were R, eight were S, and three were D points. The CF, ablation time, FTI, and power at the non-conduction blocking lesion points and other points were 12.0 g (7.0-21.5) and 12.0 g (9.0-16.0) (P = 0.9), 7.7 s (5.6-10.1) and 12.5 s (9.4-16.8) (P < 0.05), 103.0 g*s (62.0-174.5) and 149.0 g*s (104.0-213.0) (P < 0.05), and 30.0 W (22.5-30.0) and 30.0 W (30.0-30.0) (P = 0.06), respectively.

CONCLUSIONS

Shorter ablation time recorded in Visitag lead to non-conduction blocking lesion.

Awakenings from persistent vegetative state: report of three cases with parkinsonism and brain stem lesions on MRI

Three patients with a persistent vegetative state after severe head injury are reported. They recovered from a prolonged disturbance of consciousness after the administration of levodopa. These patients all had parkinsonian features. On magnetic resonance imaging, the distribution of lesions implied a diffuse axonal injury involving the substantia nigra or ventral tegmental area. The existence of patients whose dopaminergic systems may have been selectively damaged by a severe head injury should be recognised because such individuals may respond to levodopa treatment.

Perfusion-weighted MRI of spinal dural arteriovenous fistula

A 72-year-old woman was admitted with rapidly progressive paraplegia and sphincter disturbance. T2-weighted images of the thoracic spine showed intramedullary high signal with flow voids suggesting dilated medullary veins. Conventional spinal angiography demonstrated a dural arteriovenous fistula draining into perimedullary veins. Perfusion-weighted MRI demonstrated a prolonged mean transit time and increased blood volume in the high-signal area. The loss of normal perfusion gradient and venous hypertension and were thought to produce these differences. The time-to-peak was almost identical in the high-signal and isointense areas, although the bolus of contrast medium arrived earlier in the former. Arteriovenous shunting was thought to cause faster inflow. These changes may have resulted in increased blood volume in the spinal cord. The high signal has been attributed to oedema due to venous congestion, but there has been no histological confirmation. Perfusion MRI in this case supports this hypothesis.

The antioxidant EPC-K1 ameliorates brain injury by inhibiting lipid peroxidation in a rat model of transient focal cerebral ischaemia

BACKGROUND

Cerebral ischaemia-reperfusion injury is associated with the generation of reactive oxygen species during the early phases of reoxygenation. EPC-K1, a phosphate diester of vitamins C and E, has been reported to possess potent hydroxyl radical scavenging activity. This study was performed to investigate the effectiveness of EPC-K1 in attenuating cerebral ischaemia-reperfusion injury in a rat model of transient focal cerebral ischaemia.

METHOD

We evaluated the efficacy of EPC-K1 by measuring the concentration of cerebral thiobarbituric acid reactive substances (TBARS), an indicator of the extent of lipid peroxidation by free radicals, and infarct size in rats subjected to one hour of cerebral ischaemia and 4, 24, or 72 hours of reperfusion.

FINDINGS

EPC-K1 significantly reduced both the cerebral TBARS level and the infarct size in a rat model of transient focal cerebral ischaemia. These results indicate that EPC-K1 administration during the early stages of reperfusion ameliorates ischaemic brain injury by inhibiting lipid peroxidation.

INTERPRETATION

This report is the first to describe the protective mechanism of EPC-K1 by measuring both the TBARS level and infarct size in a rat model of transient focal cerebral ischaemia, and may suggest a potential clinical approach for the treatment of ischaemic cerebrovascular disease.

Intraoperative angiography in the surgical treatment of cerebral arteriovenous malformations and fistulas

BACKGROUND

The role of intraoperative angiography in the surgical treatment of cerebrovascular malformations remains controversial. The authors report on their experiences with intraoperative angiography in a series of 20 cases with cerebrovascular malformation to determine whether the use of intraoperative angiography has a favorable impact on the surgical treatment of cerebrovascular malformations.

METHODS

Intraoperative angiography was performed in the surgical resection of arteriovenous malformation in 18 patients and in the surgical obliteration of arteriovenous fistula in 2 patients. The incidence of unexpected findings, such as residual nidus, demonstrated by intraoperative angiography was determined.

FINDINGS

High-quality subtraction images were obtained by intraoperative angiography in every case and the findings prompted an additional procedure in 1 case that displayed an unexpected residual nidus (5.6%). There were no complications from the intraoperative angiography procedure.

INTERPRETATION

Intraoperative assessment of technical results prior to wound closure offers the neurosurgeon the opportunity to resect or obliterate a vascular malformation completely, obviating a second operation.

Ventricular diverticulum at the posterior horn of the lateral ventricle presenting as aplasia cutis congenita

Non-communicating hydrocephalus can cause rupture of the lateral or third ventricle, generally in the medial wall of the trigone or the posterior wall of the third ventricle, resulting in a cystic lesion known as ventricular diverticulum. In this paper, we describe a rare case of ventricular diverticulum located in the posterior horn of the lateral ventricle and expanding to bulge with a convexity reaching into the subdural space in a neonate. Aplasia cutis congenita and a bone defect were also present in the same neonate. Early surgical repair of the scalp defect and ventriculoperitoneal shunting were performed. In addition to illustrating the rare co-existence of a ventricular diverticulum at the posterior horn of the lateral ventricle and aplasia cutis congenita in a neonate, this case also offers new insights into the pathogenesis of these congenital anomalies.

Moyamoya disease associated with persistent primitive hypoglossal artery: report of a case

An 8-year-old boy presenting with a transient weakness of the left extremities had a rare association of moyamoya disease and persistent primitive hypoglossal artery (PPHA). Digital subtraction angiography demonstrated intracranial moyamoya vessels and a PPHA on the right side. There was collateral blood flow from the posterior circulation to the anterior circulation, with the PPHA functioning as a blood supplier vessel. The patient underwent multiple burr hole formation, and neovascularization via the burr holes was observed on follow-up angiography. In this case, blood flow into the posterior circulation via the PPHA, which served as the collateral vessel to the moyamoya phenomenon, may have disturbed the spontaneous closure of the PPHA. Thus, this case serves as a basis for studying important pathogenic and embryological processes that contribute to the development of these vascular abnormalities.

Laminoplasty improves respiratory function in elderly patients with cervical spondylotic myelopathy

Respiratory insufficiency after acute cervical trauma is well documented, but the relationship between respiratory function and chronic lesions, such as cervical spondylosis, has received scant attention. This clinical study investigated the effect of cervical spondylosis on respiratory function in 12 patients over 65 years of age who underwent expansive laminoplasty. Functional and neurological status were assessed using the Japanese Orthopaedic Association (JOA) scale and Neurosurgical Cervical Spine Scale (NCSS). To assess the effect of laminoplasty on respiratory function in patients with cervical spondylotic myelopathy, lung volumes including vital capacity, tidal volume (TV), inspiratory reserve volume, expiratory reserve volume, inspiratory capacity, and forced expiratory volume were measured by spirometer before surgery and 6 months after surgery. The arterial blood gas values were also measured before and after surgery. All patients showed functional improvement after surgery, and neurological examination 6 months after surgery revealed a significant improvement in both JOA scale and NCSS scores (p < 0.001). There were no significant differences in most lung volumes, but TV (p = 0.039) at 6 months after surgery showed a significant increase compared to before surgery. PCO2 also showed a significant reduction after surgery (p = 0.047). This limited study revealed that laminoplasty improved respiratory function in patients over 65 years of age with cervical spondylotic myelopathy. Lung volume measurement may be one method to estimate spinal cord function after a surgical procedure.

Venous malformation serving as the draining vein of an adjoining arteriovenous malformation. Case report and review of the literature

BACKGROUND

Widely accepted pathologic classification of venous malformations includes discrete venous, arteriovenous, capillary, and cavernous malformations, each with distinct pathological criteria for definition. Several authors have described mixed or transitional vascular malformations with pathological features of more than one type of malformation within the same lesion. We present a rare case of a venous malformation associated with an arteriovenous malformation (AVM).

CASE DESCRIPTION

A 37-year-old woman presented with a loss of consciousness. Computed tomography showed an enlarged vein running along the lateral wall of the right lateral ventricle. A cerebral angiogram demonstrated an AVM and a venous malformation in the right hemisphere; the AVM and the venous malformation were located in proximity to each other with the AVM using the venous malformation as its draining vein. In this case, where an AVM used the venous malformation as the draining vein, only the AVM was treated by proton-beam radiosurgery. Follow-up magnetic resonance angiography demonstrated complete obliteration of the AVM with the venous malformation remaining unchanged.

CONCLUSION

Arteriovenous shunting would have disturbed venous drainage resulting in the development of the venous malformation. Thus, in addition to demonstrating a rare coexistence of AVM and venous malformation, this case also offers a new insight into the pathogenesis of these vascular malformations.

[Congestive heart failure caused by the thyroid stimulating hormone(TSH) secreting pituitary adenoma: report of two cases]

A 42-year-old man and a 31-year-old man with congestive heart failure caused by the thyroid stimulating hormone(TSH) secreting pituitary adenoma were reported. Heart failure was improved after transsphenoidal resection of the pituitary adenoma in each patient. The syndrome of inappropriate secretion of TSH causes hyperthyroidism. Thyroid hormone acts directly on cardiac muscle to increase the stroke volume. Hyperthyroidism itself reduces the peripheral vascular resistance and an elevated basal metabolism which is the basic physiologic change in hyperthyroidism dilates small vessels and reduces vascular resistance. The reduced vascular resistance contributes to increase stroke volume. Thyroid hormone also acts directly on the cardiac pacemakers to be apt to cause tachycardiac atrial fibrillation. These mechanical changes in hyperthyroidism increase not only the cardiac output but also the venous return. The increased blood volume and the shortened ventricular filling time due to tachycardia result in congestive heart failure. TSH secreting pituitary adenoma is a rare tumor, however heart failure is common disease. TSH secreting pituitary adenoma should be taken into consideration in patients with heart failure. The presented cases were very enlightening to understand the relation between brain tumor and heart disease.