In the face and neck, keloid scar distribution is related to skin thickness and stiffness changes associated with movement

Keloid scars tend to occur in high-tension sites due to mechanical stimuli that are involved in their development. To date, a detailed analysis of keloid distribution focused specifically on facial and neck areas has not been reported, and limited literature exists as to the related mechanical factors. To rectify this deficiency of knowledge, we first quantified the facial and neck keloid distribution observed clinically in 113 patients. Subsequently, we performed a rigorous investigation into the mechanical factors and their associated changes at these anatomic sites in healthy volunteers without a history of pathologic scarring. The association between keloid-predilection sites and sebaceous gland-dense and acne-prone sites was also examined. To assess skin stretch, thickness and stiffness, VECTRA, ultrasound and indentometer were utilised. Baseline skin stiffness and thickness were measured, as well as the magnitude of change in these values associated with facial expression and postural changes. Within the face and neck, keloids were most common near the mandibular angle (41.3%) and lateral submental (20.0%) regions. These areas of increased keloid incidence were not associated with areas more dense in sebaceous glands, nor linked consistently with acne-susceptible regions. Binomial logistic regression revealed that changes in skin stiffness and thickness related to postural changes significantly predicted keloid distribution. Skin stiffness and thickness changes related to prolonged mechanical forces (postural changes) are most pronounced at sites of high keloid predilection. This finding further elucidates the means by which skin stretch and tension are related to keloid development. As a more detailed analysis of mechanical forces on facial and neck skin, this study evaluates the nuances of multiple skin-mechanical properties, and their changes in a three-dimensional framework. Such factors may be critical to better understanding keloid progression and development in the face and neck.

The effects of systemic diseases, genetic disorders and lifestyle on keloids

Keloid are a fibroproliferative disorder caused by abnormal healing of skin, specifically reticular dermis, when subjected to pathological or inflammatory scars demonstrating redness, elevation above the skin surface, extension beyond the original wound margins and resulting in an unappealing cosmetic appearance. The severity of keloids and risk of developing keloids scars are subjected to elevation by other contributing factors such as systemic diseases, general health conditions, genetic disorders, lifestyle and natural environment. In particular, recently, daily physical work interpreted into mechanical force as well as the interplay between mechanical factors such as stress, strain and stiffness have been reported to strongly modulate the cellular behaviour of keloid formation, affect their location and shape in keloids. Herein, we review the extensive literature on the effects of these factors on keloids and the contributing predisposing mechanisms. Early understanding of these participating factors and their effects in developing keloids may raise the patient awareness in preventing keloids incidence and controlling its severity. Moreover, further studies into their association with keloids as well as considering strategies to control such factors may help clinicians to prevent keloids and widen the therapeutic options.

Ear Keloid as an Unusual Complication of Prolonged Mask Use during the COVID-19 Pandemic

The recent COVID-19 pandemic required many people to wear ear-loop face masks (ELFMs) for protracted periods, and ear injuries have been reported. Here, we report a rare case of a keloid on the right posterior ear that appeared to arise from prolonged ELFM use. A 76-year-old Japanese man presented with a 7.3 × 2.2 × 1.4-cm keloid running from the medial retroauricular sulcus to the posterior lobule. The lack of keloid history suggested the absence of genetic risk factors. The patient reported extensive mask-wearing habits that were augmented by the pandemic. The keloid developed from an ear injury. Although it healed well, it started thickening 2 months later. Because local mechanical forces (eg, pressure/friction) can promote keloid growth, the ELFM may have provoked the keloid. The patient disclosed a history of uncontrolled hypertension and diabetes mellitus, which associate with severe keloids. The whole keloid was removed via total excision, and the defect was closed primarily and subjected to 15Gy/2Fr radiotherapy. The patient was advised to use a different mask type. Twelve months later, the scar had healed without complications or recurrence and with good cosmetic outcomes. Thus, ELFMs can promote retroauricular keloid formation, possibly by imposing local pressure/friction. ELFMs may also raise local skin temperatures and humidity, thereby fostering infection, which can trigger keloids. Hypertension/diabetes may further elevate the risk of EFLM-induced keloid. Thus, an auricular keloid is an unusual complication of prolonged ELFM use. Combination therapy can have excellent outcomes. Patients with keloid risk factors should be advised to use face masks without ear loops.

Allometrically scaling tissue forces drive pathological foreign-body responses to implants via Rac2-activated myeloid cells

Small animals do not replicate the severity of the human foreign-body response (FBR) to implants. Here we show that the FBR can be driven by forces generated at the implant surface that, owing to allometric scaling, increase exponentially with body size. We found that the human FBR is mediated by immune-cell-specific RAC2 mechanotransduction signalling, independently of the chemistry and mechanical properties of the implant, and that a pathological FBR that is human-like at the molecular, cellular and tissue levels can be induced in mice via the application of human-tissue-scale forces through a vibrating silicone implant. FBRs to such elevated extrinsic forces in the mice were also mediated by the activation of Rac2 signalling in a subpopulation of mechanoresponsive myeloid cells, which could be substantially reduced via the pharmacological or genetic inhibition of Rac2. Our findings provide an explanation for the stark differences in FBRs observed in small animals and humans, and have implications for the design and safety of implantable devices.

Adherent Abdominal Scar Revision Does Not Require Total Scar Removal

Abdominal surgery can cause notable scars that adhere to the abdominal tissues below. Full scar removal is generally not recommended due to the risk of intestinal damage and delayed wound healing. Here, we describe a surgical scar-revision procedure for adherent abdominal scars that does not involve either opening the abdominal cavity or total scar removal. A 58-year-old woman exhibited an aesthetically displeasing hypertrophic adherent abdominal scar that extended from the umbilical fold to the pubic area and distorted the umbilicus. It arose from multiple laparotomies for hernia repair and subsequent complications. Pain/discomfort and functional impairment were absent. Scar-revision surgery was conducted under general anesthesia. The skin around the adherent scar was excised down to the subcutaneous layer with a minimal margin. However, only the epidermis and superficial dermal layer of the adherent scar were removed; the deep scar dermis remained. The skin flaps on either side of the midline were then advanced and sutured over the remnant dermis. One year after surgery, the aesthetic and functional outcomes were excellent. Furthermore, no hypertrophic scars or epidermal cysts were found. This technique is effective, efficient, does not involve intraabdominal procedures, provides a vascularized tissue layer, and results in an aesthetically pleasing scar.

Keloidal Collagen May Be Produced Directly by αSMA-positive Cells: Morphological Analysis and Protein Shotgun Analysis

Keloids are fibroproliferative lesions caused by abnormal dermal wound healing. Keloidal collagen (KC) is a pathognomic feature of keloids, but the mechanism by which it forms is unknown. This study aimed to evaluate the histopathology of KC and thereby gain clues into how it forms.

Methods

The cross-sectional study cohort consisted of a convenience series of patients with keloids who underwent surgical excision. Skin pieces (3 mm²) were collected from the keloid center and nearby control skin. Histopathology was conducted with light and electron microscopy and immunohistochemistry. KC composition was analyzed with protein shotgun analysis.

Results

Microscopic analyses revealed the ubiquitous close association between KC and αSMA-positive spindle-shaped cells that closely resembled myofibroblasts. Neither KC nor the spindle-shaped cells were observed in the control tissues. Compared with control skin, the collagen fibers in the KC were overall thinner, their diameter varied more, and their spacing was irregular. These features were particularly pronounced in the collagens in the vicinity of the spindle-shaped cells. Protein shotgun analysis did not reveal a specific collagen in KC but showed abnormally high abundance of collagens I, III, VI, XII, and XIV.

Conclusions

These findings suggest that KC may be produced directly by myofibroblasts rather than simply being denatured collagen fibers. Because collagens VI and XII associate with myofibroblast differentiation, and collagen XIV associates with local mechanical stress, these collagens may reflect, and perhaps contribute to, the keloid-specific local conditions that lead to the formation of KC.

Congress Report on the Second World Congress of Global Scar Society with Scar Academy and Japan Scar Workshop

Pathological scars (including keloids, hypertrophic scars, and scar contractures) are present with high severity among certain populations, particularly in Asians and Africans who are highly prone to develop scars. Understanding the patho-mechanism that underlies scarring, such as mechanosignaling, systemic, and genetic factors, as well as optimal surgical techniques and integrated noninvasive therapeutic methods can guide clinicians to develop treatment protocols that can overcome these issues. This report summarizes a congress at Pacifico Yokohama (Conference Center) on December 19, 2021 involving researchers and clinicians from diverse disciplines who convened to discuss current clinical, preclinical, and most recent research advances in understanding pathological scarring, keloid and hypertrophic scar management, and research progress in wound healing. Presenters described the advances in scar therapies, understanding scarring mechanisms, and scar prevention and assessments tools. Moreover, presenters addressed the challenges during the COVID-19 pandemic and using telemedicine in management of scar patients.

Combination Therapy for a Severe Axillary Keloid with Abscesses: A Case Report

Keloids are laterally growing fibroproliferative skin disorders. Severe keloids spread widely, sometimes over joints, thus significantly limiting motor function. They are associated with recurrent, very painful draining infections. Here, we report a case of a giant keloid that was successfully treated by combination therapy comprising surgery (partial resection followed by local flap transposition) and subsequent radiotherapy and steroid-plaster therapy. The keloid was first noticed when the patient was 7 years old at the site of a Bacille Calmette-Guérin vaccination she had received on her left shoulder in infancy. The keloid grew rapidly and widely after adulthood. A malignant tumor was suspected at another hospital, but a biopsy at age 45 years indicated the lesion was a keloid. Later, the keloid grew from the shoulder onto the chest and back and over the anterior axilla. At age 62 years, the patient was referred to our hospital. Under general anesthesia, the keloid was partially resected and the wound was covered with a local flap. Postoperative radiotherapy was performed 1 week later. The residual keloid was treated for 18 months with steroid tape. At 18 months after surgery, no recurrence of the keloid was observed. The patient had no pain or movement restriction. She was extremely satisfied with the results and considered the treatment to have improved her quality of life. While a standard strategy for severe keloid remains to be established, combination therapy comprising surgery, postoperative radiotherapy, and steroid-plaster therapy that aims to reduce inflammation and skin tension may be an option.

Testing mosses exposed in bags as biointerceptors of airborne radiocaesium after the Fukushima Dai-ichi Nuclear Power Station accident

Eight years after the Fukushima nuclear accident, mosses exposed in bags were used to investigate their ability to accumulate radiocaesium and therefore to act as biointerceptors of ¹³⁴Cs and ¹³⁷Cs in the evacuated area of the Fukushima territory. Bags were filled with 3 widely studied moss species (Sphagnum palustre, Hypnum cupressiforme, and Hypnum plumaeforme) and exposed for 3, 6 or 9 weeks at 5 former residential sites within the Fukushima area and, for comparison, at three background sites located 700 km away. The radiocaesium activity concentrations found in moss bags were evaluated as function of exposure time, site conditions and moss species. In the Fukushima area, the moss bags accumulated ¹³⁷Cs at all exposure sites and in all exposure periods, with S. palustre having the highest ¹³⁷Cs accumulation ability. The ¹³⁷Cs activity concentrations (from 28 to 4700 Bq kg^-1) measured in moss bags increased with the exposure time and were consistent with the decontamination status of each exposure site, highlighting the big potential of moss bags to discriminate among exposure sites. Time dependency of ¹³⁷Cs activity concentrations measured in mosses allowed the calculation of location-specific and species-specific factors, which can be used to predict radiocaesium accumulation trends in future biomonitoring surveys performed in the same area with the same experimental design. Autoradiography and electron microscopy analyses of the moss surfaces revealed a prevalence of soil-derived particulate form of radiocaesium, suggesting the use of moss bags as warning sensors of resuspended particles potentially harmful for local residents.

Fibroma of the tendon sheath in the dorsum of the foot: A case report

Fibroma of tendon sheath (FTS) is a rare soft tissue tumor that usually occurs in the upper extremity. Moreover, of the few cases reported in the feet, nearly all occur in the plantar region. We report the case of a large FTS in the dorsum of the left foot that grew quickly into a 4 cm-diameter lesion. The 44-year-old Japanese man noticed the tumor incidentally one year before presentation and could not recall any possible cause. Physical examination showed an elastic hard mass that spread over the third to fifth metatarsal bones. MRI showed iso-intense signals with central hypo-intensity on T1-weighted images and hypo-intense signals on T2-weighted images. Since a biopsy did not reveal any malignant findings, the lesion was excised surgically. The tumor was found to be multilocular, encapsulated, and to arise from the extensor digitorum brevis tendon. Histopathology showed scattered spindle fibroblasts and slit-like vascular structures within the dense collagenous matrix. The tumor was diagnosed on the basis of the clinical, demographic, surgical, and histopathological findings as an FTS arising from the extensor digitorum brevis tendon. A review of the literature revealed seven cases of FTS of the dorsum of the foot, which indicates its rarity. More than one-half of these cases were from Japan. While the cause of FTS remains unclear, trauma has been implicated. We suggest that the cultural background of the patient, which could promote kneeling-induced dorsal foot trauma, may have contributed to the onset/progression of our case. Level of Clinical Evidence: 4.

Keloidal dermatofibroma: Clinicopathological comparison of 52 cases with a series of 2077 other dermatofibromas

Dermatofibroma is a common benign skin lesion with a contested etiology: some believe it is a neoplasm while others propose minor injuries initiate it. Many dermatofibroma variants have been described, including keloidal dermatofibroma, which is unusual by bearing keloidal collagen. Keloidal dermatofibroma was first described in 1998 and only 15 cases have been reported. Since keloids are driven by skin injuries, the existence of keloidal dermatofibroma has been suggested to support the injury hypothesis of dermatofibroma etiology. To better understand keloidal dermatofibroma characteristics and gain clues regarding dermatofibroma etiology, consecutive keloidal dermatofibroma cases (n = 52) and dermatofibroma without keloidal collagen (n = 2077) that were histopathologically diagnosed in 2016-2019 were identified from the records of a Japanese dermatopathology laboratory and compared in terms of demographic, clinical, and histopathological characteristics by univariate analyses. Compared to other dermatofibromas, keloidal dermatofibromas occurred more frequently on the forearm and hand (P < 0.0001 and 0.0019), especially the wrist dorsum, and in the superficial skin layer (P < 0.0001). Keloidal dermatofibromas also demonstrated more cellularity and hemorrhage (both P < 0.0001). Correlation analyses between keloidal collagen amount and keloidal dermatofibroma size (a proxy of time-since-onset) did not support the notion that keloidal collagen deposition and keloidal dermatofibroma formation are triggered simultaneously. Recent injury, as indicated by fresh hemorrhage, was equally common in putatively older and younger keloidal dermatofibromas. Thus, keloidal collagen in keloidal dermatofibromas could be due to injury to preexisting dermatofibromas, which suggests that the keloidal dermatofibroma entity does not prove the injury hypothesis. Commonalities between keloids and keloidal dermatofibromas suggest a link between genetics, provocative events that induce myofibroblast differentiation, and keloidal collagen production.

Vesicocutaneous fistula due to vesical diverticulitis with stones: A case report and literature review

Introduction

We encountered an extremely rare case of a vesicocutaneous fistula due to vesical diverticulitis with stones.

Case presentation

A 78-year-old male patient presented to our department with complaints of suppurative discharge in the suprapubic area. Computed tomography revealed an enlarged prostate, a vesical diverticulum with stones located on the ventral side, and an aberrant connection between the anterior bladder wall and the external surface of the skin. The patient was diagnosed with a vesicocutaneous fistula due to vesical diverticulitis and was successfully treated with a multidisciplinary approach including vesical diverticulectomy with stone removal and nonviable tissue debridement. The patient continues to receive regular outpatient follow-ups with urinary catheter changes.

Conclusion

Vesicocutaneous fistulas due to vesical diverticulitis with stones are extremely rare. We should be aware that a vesical diverticulum with stones located on the ventral side might pose a high-risk factor for the formation of a vesicocutaneous fistula in elderly patients.

Additional clinical impact of plaque analysis for on-site CT-derived FFR in coronary CT angiography on midterm prognosis

Background

We previously reported that per-patient on-site computed tomography-fractional flow reserve (CT-FFR), which can be acquired on-site workstation using fluid structure interaction during the multiple optimal diastolic phases measured 1 to 2 cm distal to a target lesion may be feasible for risk stratification based on future cardiac events for patients who did not undergo planned revascularization. However, per-vessel CT-FFR and the additional impact of plaque analysis on CT-FFR have not been evaluated.

Purpose

The aim of this study is to assess the clinical and additional impact of novel plaque analysis using labeling method for per-vessel CT-FFR on midterm prognosis.

Methods

A total of 254 consecutive patients with 354 vessels showing 50–90% stenosis but not revascularized within 90 days from coronary CT angiography (CCTA) on 320-row CT were retrospectively analyzed and followed during a median follow up 3.6 years. Plaque characteristics by labeling method (necrotic core/total plaque volume (% necrotic core), non-calcified plaque (NCP)/vessel volume (%NCP), and total plaque/vessel volume (%total plaque) for both total vessel volume (mm3) and at minimum lumen area (MLA, mm2)), positive remodeling (PR) and CT-FFR were analyzed on per-target vessels. The endpoint was vessel oriented-composite outcome (VOCO), including cardiac death, non-fatal MI, and unplanned revascularization.

Results

The incidence of VOCO occurred in 6.8% (24/354). In the cox proportional hazard model, a multivariate analysis identified CT-FFR≤0.80 was the most associated factor with VOCO (all values &lt;0.01 for other plaque morphologies), but %necrotic core, %NCP, %total plaque at MLA and PR were significantly independent of CT-FFR≤0.80. (%necrotic core HR; 3.43 (p&lt;0.01 [95% confidence interval (CI) 1.42–8.29]), %NCP HR; 4.05 (p=0.03 [95% CI 1.19–13.71]), %total plaque at MLA HR; 2.82 (p=0.02 [95% CI 1.18–6.76]), and PR HR; 2.90 (p&lt;0.01 [95% CI 1.30–6.51]), respectively.)

Conclusion

From a view point of clinical outcomes for vessels with moderate to severe stenosis but not revascularized at initial CCTA, CT-FFR demonstrated the significant impact on per-vessel analysis. Moreover, %necrotic core, %NCP and %total plaque at MLA analyzed by labeling method provided better prognostic value in addition to CT-FFR.

Funding Acknowledgement

Type of funding sources: None.

Clinical trajectory and outcomes of patients with heart failure with preserved ejection fraction with normal or indeterminate diastolic function

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) is a chronic and progressive disease, but limited therapeutic strategies are currently available. Although left ventricular diastolic dysfunction (DD) is a prominent mechanism of HFpEF, a certain number of patients with HFpEF have a normal diastolic function (ND) or indeterminate diastolic function (ID). With the progressive nature of HFpEF, diastolic function may change over time. However, the change of diastolic function, its predictor and prognosis in patients with clinically established HFpEF remains unknown.

Purpose

To investigate the clinical trajectory and outcomes of patients with HFpEF with ND or ID and to identify factors associated with progression from ND or ID at discharge to DD at 1-year follow-up.

Methods

Using data from a prospective multicenter observational study of patients with HFpEF, we extracted 289 patients with HFpEF with ND or ID at discharge who had echocardiographic data at 1-year follow-up for the re-evaluation of diastolic function. Diastolic function was assessed according to the 2016 American Society of Echocardiography recommendations. Patients were classified according to the absence or presence of progression from ND or ID to DD at 1 year. The primary endpoint was a composite of all-cause death and HF rehospitalization.

Results

Median age was 81 years, and 138 (47.8%) patients were female. At 1 year, 107 (37%) patients progressed to DD. During a median follow-up of 709 days, the composite endpoint occurred in 90 (31.1%) patients. Compared to patients without progression to DD, those with progression to DD had a significantly higher cumulative incidence rate of the composite endpoint (incidence rate: 11.7/100 person-year versus 23.3/100 person-year, P&lt;0.001). Progression to DD (adjusted HR: 2.014, 95% CI: 1.239–3.273, P=0.005) was independently associated with the composite endpoint. Age (adjusted OR: 1.046, 95% CI: 1.008–1.087, P=0.018), body mass index (BMI) (adjusted OR: 1.107, 95% CI: 1.029–1.192, P=0.006), and serum albumin (adjusted OR: 0.459, 95% CI: 0.216–0.974, P=0.042) were independently associated with progression from ND or ID to DD at 1 year.

Conclusion

More than one-third of patients with HFpEF with ND or ID progressed to DD at 1 year and had poor clinical outcomes. Age, BMI, and serum albumin were independently associated with this progression.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from Japan Society for the Promotion of Science KAKENHI (No. JP 17K09496) and Japan Agency for Medical Research and Development (No. JP16lk1010013).

Association between prognosis and the use of angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blocker in frail patients with heart failure with preserved ejection fraction

Background

The effectiveness of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) has not been demonstrated in patients with heart failure with preserved ejection fraction (HFpEF). We recently reported significant interaction between the use of ACE-I and/or ARB (ACE-I/ARB) and frailty on prognosis in patients with HFpEF.

Purpose

In the present study, we examined the association between ACE-I/ARB and prognosis in patients with HFpEF stratified by the presence or absence of frailty.

Methods

We examined the association between the use of ACE-I/ARB and prognosis according to the presence (Clinical Frailty Scale (CFS) ≥5) or absence (CFS ≤4) of frailty in patients with HFpEF in a post-hoc analysis of registry data. Primary endpoint was the composite of all-cause mortality and heart failure admission. Secondary endpoints were all-cause mortality and heart failure admission.

Results

Of 1059 patients, median age was 83 years and 45% were male. Kaplan-Meier analysis showed that the risk of composite endpoint (log-rank P=0.001) and all-cause death (log-rank P=0.005) in patients with ACE-I/ARB was lower in those with CFS ≥5, but similar between patients with and without ACE-I/ARB in patients with CFS ≤4 (composite endpoint: log-rank P=0.830; all-cause death: log-rank P=0.192). In a multivariable Cox proportional hazards model, use of ACE-I/ARB was significantly associated with lower risk of the composite endpoint (hazard ratio = 0.52, 95% CI: 0.33–0.83, P=0.005) and heart failure admission (hazard ratio = 0.45, 95% CI: 0.25–0.83, P=0.010) in patients with CFS ≥5, but not in patients with CFS ≤4 (composite endpoint: hazard ratio = 1.41, 95% CI: 0.99–2.02, P=0.059; heart failure admission: hazard ratio = 1.43, 95% CI: 0.94–2.18, P=0.091). The association between ACE-I or ARB and prognosis did not significantly differ by CFS (CFS ≤4: log-rank P=0.562; CFS ≥5: log-rank P=0.100, for with ACE-I vs. ARB, respectively). Adjusted HRs for CFS 1–4 were higher than 1.0, but were less than 1.0 at CFS 5.

Conclusions

In patients with HFpEF, use of ACE-I/ARB was associated with better prognosis in patients with frailty as assessed with the CFS, but not in those without frailty.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche

Premature atrial contraction on Holter electrocardiogram predicts the recurrence of atrial fibrillation after catheter ablation

Introduction

It is important to detect the recurrence of atrial fibrillation (AF) after catheter ablation (CA) early, but the method of detection has not been established. The purpose of this study is to determine whether 24-h Holter electrocardiogram (ECG) can predict the recurrence of AF after CA.

Methods

We studied 336 patients of 497 patients enrolled in EARNEST-PVI trial to investigate whether the total number of premature atrial contraction (PAC) and the maximum number of PAC run by 24-h Holter ECG at 6 months after CA predicted AF recurrence after 6 months. We excluded 86 patients with recurrence by 6 months after CA and 75 patients without Holter ECG at 6 months after CA.

Results

Median age was 66 years, male were 77% and median follow-up period was 1138 days. Receiver operating characteristic curve analysis identified the total number of PAC ≥270 beats and the maximum number of PAC run ≥8 beats as the optimal cutoff for prediction of AF recurrence. Kaplan-Meier analysis showed patients with the total number of PAC ≥270 beats had more frequent AF recurrence than those without (Kaplan-Meier estimated 3-year AF recurrence rate 34% vs. 17%, Log-rank P=0.001) and patients with the maximum number of PAC run ≥8 beats had more frequent AF recurrence than those without (Kaplan-Meier estimated 3-year AF recurrence rate 33% vs. 20%, Log-rank P=0.006). Multivariate analysis revealed that the total number of PAC ≥270 beats and the maximum number of PAC run were significantly associated with AF recurrence (hazard ratio [95% confidence interval] 1.83 [1.16–2.91], P=0.01 and 1.01 [1.01–1.02], P=0.001, respectively)

Conclusion

The total number of PAC and the maximum number of PAC run on the Holter ECG may be useful in predicting AF recurrence after CA.

Funding Acknowledgement

Type of funding sources: None.

Impact of heart rate reduction on recurrence after catheter ablation of persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

OnBehalf

OCVC Arrhythmia Investigators

Background

Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF).

Purpose

To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively.

Results

There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p &lt;0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p &lt;0.001) and was negatively associated with post-ablation HR (r = - 0.37, p &lt;0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557–0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, &lt;14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20–4.51; p = 0.013).

Conclusions

There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Comparison of clinical effect of living alone between urban area and rural area in patient with acute coronary syndrome

Background and objective

Living alone is reported as an independent risk factor for worse clinical outcomes after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Manifestations of psychological stress such as depression and anxiety in patients living alone is thought to be associated with subsequent cardiovascular events. The impact of living alone on the psychological factors of patients may be differ depending on their living environment. However, comparison of the effects of living alone in different living environment on the prognosis of patients with ACS has not been reported.

Purpose

The aim of the present study was to compare the clinical effect of living alone on clinical outcomes in patients with ACS between urban area and rural area.

Methods

Data from a multi-center, observational study of consecutive patients who underwent emergency PCI for ACS between January 2012 and December 2016 were analyzed. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE). MACCE was defined as composite of cardiovascular death, ACS, and stroke.

Results

In this study, 1349 patients were enrolled and divided into two population according to their living environment: urban area population (n=417), and rural area population (n=932). In urban area population, 87 patients (20.9%) were living alone, and 330 (79.1%) were living together. In rural area population, 169 (18.1%) were living alone, and 763 (81.9%) were living together. There are no significant differences in baseline characteristics between the living alone group and the living together group in both urban area population and rural area population. During a median follow-up period of 2.1 years, Kaplan-Meier curves showed the living alone group had higher risk of MACCE than the living together group in urban area population (log-rank, p=0.01). On the other hands, there are no significant differences in the incidences of MACCE between two groups in rural area population (p=0.86). After adjustment for other covariates, the living alone was significantly associated with MACCE (hazard ratio [HR], 2.83; 95% confidential interval [CI], 1.16–6.91; p=0.02) compared with the living together group in urban area population. However, in rural area population, the living alone group was not significantly associated with MACCE (HR, 1.02; 95% CI, 0.66–1.57; p=0.92) compared with the living together group.

Conclusion

Living alone was significantly associated with worse clinical outcomes after emergency PCI of ACS in urban area but not in rural area.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Reappraising the role of baseline plasma C-reactive protein levels on recurrence after catheter ablation of persistent atrial fibrillation: insight from EARNEST-PVI trial

Background

Subclinical inflammation is an important pathogenesis of developing and sustaining atrial fibrillation (AF). Because AF itself contribute to the inflammatory response, the role of baseline subclinical inflammation on AF recurrence after catheter ablation (CA) remains controversial in patients with persistent AF.

Purpose

To evaluate whether baseline plasma C-reactive protein (CRP) levels, a sensitive marker of inflammation, are associated with AF recurrence following CA.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. A total of 441 patients (median age, 67 years; 26% female; 25% long-standing persistent AF) whose plasma CRP levels were measured at baseline were included in this study.

Results

At baseline, a median (interquartile range) of plasma CRP level was 0.10 [0.06–0.19] mg/dl. Plasma CRP levels significantly increased at discharge (0.83 [0.21–1.84] mg/dl, p&lt;0.001) and decreased 1 year after CA (0.10 [0.05–0.20] mg/dl, p=0.040) compared to the baseline value. During the follow-up of 1 year, 115 patients (26%) experienced AF recurrence, and the incidence was significantly higher in 124 patients with low CRP levels at baseline (cut-off ≤0.06 mg/dl) than the other 317 patients (33.9% vs. 23.0%, p=0.017). After adjustment of age, gender, body mass index, long-standing persistent AF, CA strategy, and plasma brain natriuretic peptide levels, low plasma CRP levels was a significant predictor of AF recurrence (hazard ratio, 1.51; 95% confidence interval, 1.02–2.24; p=0.042).

Conclusions

Low plasma CRP levels at baseline predicted AF recurrence in the EARNEST-PVI trial. Reappraising the role of CRP on AF recurrence may be needed in patients with persistent AF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

Comparison of clinical outcomes between percutaneous coronary intervention for the de novo lesion versus in-stent restenosis lesion

Background and objective

Percutaneous coronary intervention (PCI) with metallic coronary stent (bare-metal stents [BMS] and drug-eluting stents [DES]) implantation is most frequently performed therapeutic procedures for coronary artery disease. In-stent restenosis (ISR) is a critical drawback of metallic coronary stents. Incidence of ISR has been reported in up to 30% after BMS implantation. The use of DES has greatly reduced the proportion of restenosis compared with the BMS. However, ISR still remains the primary concern after PCI even in the contemporary DES era, and thought to be associated with worse clinical outcomes. However, comparative data on ISR and de novo lesions are rare.

Purpose

The aim of the present study was to compare the clinical outcomes after PCI for the de novo lesion and the ISR lesion.

Methods

We performed a retrospective analysis of patients who underwent PCI between 2013 and 2020. The incidences of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death were evaluated. MACCE was defined as composite of cardiovascular death, non-fatal myocardial infarction, and stroke.

Results

In this study, 1538 patients were enrolled and divided into two groups: PCI for de novo lesion group (n=1258, 81.8%), and PCI for ISR lesion group (n=280, 18.2%). Patients in the ISR lesion group were significantly older and had higher prevalence of hypertension, diabetes mellitus, dyslipidemia and chronic kidney disease than patients in the de novo lesion group. During a median follow-up period of 1.9 years, Kaplan-Meier curves showed no significant differences in the incidences of MACCE (log-rank, p=0.86) and all-cause death (p=0.84) between two groups. After adjustment for other covariates, PCI for ISR lesion were not significantly associated with MACCE (hazard ratio [HR], 1.10; 95% confidential interval [CI], 0.61–1.97; p=0.76) and all-cause death (HR, 0.93; 95% CI, 0.56–1.56; p=0.79)

Conclusion

PCI for the ISR lesion was not associated with worse clinical outcomes compared with PCI for the de novo lesion.

Funding Acknowledgement

Type of funding sources: None.

Optimal measurement location of on-site based CT-derived FFR on midterm prognosis

Background

Fractional Flow Reserve (FFR) derived from coronary computed tomography angiography (CCTA) enables anatomical and hemodynamical assessment of coronary artery disease. CT-FFR, which can be acquired on-site workstation using fluid structure interaction during the multiple optimal diastolic phase, has an incremental diagnostic value over conventional CCTA. However, few studies are focused on investigating the appropriate measurement location of CT-FFR, considering the prognosis, using CCTA as a standalone modality.

Purpose

The aim of this study is to assess the clinical impact on CT-FFR with an appropriate measurement.

Methods

A total of 370 consecutive patients who underwent CCTA in a single-heartbeat scan with a phase window of 70% to 99% of the R-R interval, showing 50–90% stenosis of at least one major epicardial vessel measuring ≥1.8 mm in diameter on CCTA were retrospectively analyzed and followed during a median follow up 2.9 years. CT-FFR values were measured at three points: 1, 2 cm distal to a target lesion (CT-FFR1cm, 2cm) and the vessel terminus (CT-FFRlowest), and a CT-FFR value ≤0.80 was considered abnormal. The endpoint was MACE, a composite of cardiac death, non-fatal MI, and unplanned revascularization.

Results

The incidence of MACE occurred in 8.4% (31/370) of the whole patients, including four cardiac deaths, ten all cause deaths, two non-fatal MI, and twenty unplanned revascularization. The Kaplan-Meier survival analysis demonstrated a significantly higher cumulative MACE rate in patients with positive CT-FFR1cm and 2cm than those with negative CT-FFR1cm and 2cm, while there was no significant difference between negative and positive in CT-FFRlowest, among patients with negative CT-FFR1cm and 2cm (Figure 1). Among 221 patients, who did not perform early revascularization within 90 days from CCTA, there was no significant difference in CT-FFRlowest in the incidence of MACE. In contrast, the risk of MACE was significantly higher in both positive CT-FFR1cm and CT-FFR2cm (Figure 2).

Conclusion

From a view point of clinical outcome for patients with moderate to severe stenosis on CCTA, a CT-FFR value when measured at 1-to-2 cm distal to a target lesion could be feasible for the deferral of unnecessary invasive coronary angiography safely. Moreover, CT-FFR1–2cm showed better risk stratification measurement rather than CT-FFRlowest, based on future adverse cardiac event.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Canon Medical Systems Corporation Kaplan-Meier 1Kaplan-Meier 2

The relationship among extent of lipid-rich plaque, factors associated with a reduction of lipid-rich plaque and late lumen loss: a near-infrared spectroscopy and intravascular ultrasound study

Background

Near-infrared spectroscopy (NIRS) and intravascular ultrasound (IVUS) are useful imaging modalities to identify lipid-rich plaque (LRP) which is associated with an increased risk of future cardiovascular events in individuals undergoing PCI. Pathological studies have raised concerns that treating LRP with stents may impair vascular healing. However, the impact of stent implantation to LRP lesions was less known. Moreover, little information is available about changes in the extent of LRP at before and after PCI.

Purpose

The aim of this study was to investigate changes in LRP by NIRS between pre- and post-stent implantation, and to evaluate an association among impact of LRP by NIRS at pre- and post-stenting and late lumen loss (LLL) by angiography.

Methods

We studied 175 lesions in 149 patients who underwent PCI under NIRS-IVUS guidance and follow-up angiography at 8-month later from 2017 to 2020. Plaque characteristics on IVUS, the extent of LRP [defined as a long segment with a 4-mm maximum lipid core burden index (maxLCBI4mm)] on NIRS, and quantitative coronary angiography measurements were analyzed. We evaluated a change of the extent of LRP between pre- and post-stenting at index PCI procedure, and association between the extent of LRP and a 8-month LLL at follow-up coronary angiography. A large LRP was defined as maxLCBI4mm&gt;400 at pre-stenting.

Results

Mean age was 64.5 years old, and 123 (82%) patients were male. The prevalence of large LRP was 51% and median plaque burden at minimum lumen area was 81%. The extent of LRP at culprit lesion significantly decreased from pre- to post-stenting (median maxLCBI4mm [interquartile range (IQR)]: 407 [199, 580] to 133 [13, 319], p&lt;0.001) (Figure 1). In multivariable liner regression analysis, independent predictors for the reduction of LRP were a pre-stenting LRP (β coefficient = −57.0, 95% confidence interval (CI) [−65.1 to −48.8], p&lt;0.001) and plaque burden (β coefficient = −30.0, 95% CI [−56.6 to −3.4], p&lt;0.001), respectively. On the other hands, patient comorbidities, lipid profile and inflammatory markers were not associated with the reduction of LRP (all p&gt;0.05). Median LLL at follow-up angiogram was 0.17 [0.07–0.35] mm. Both the extent of pre- and post-stenting LRP were not associated with LLL (r=0.018, p=0.80 and r=0.022, p=0.76, respectively) (Figure 2). In addition, there was no significant difference in LLL between the post-stenting large and non-large LRP (median [IQR] 0.18 [0.08–0.35] vs. 0.17 [0.07–0.35]; P=0.95).

Conclusions

This study showed coronary stent implantation significantly reduced the NIRS-derived LRP in patients undergoing PCI. Although the extent of pre-stenting LRP and IVUS plaque burden predicted the reduction of LRP, the extent of pre- and post-stenting LRP were not associated with LLL. These findings suggest that stent implantation for LRP, even in a large LRP, is safe and does not affect LLL.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Scatter plotsFigure 2. CENTRAL Figure

Renal function and arrhythmia outcomes in persistent atrial fibrillation patients after catheter ablation: subanalysis of the EARNEST-PVI trial

Background

Atrial fibrillation (AF) reduces the renal function. Renal dysfunction and AF often coexist. Catheter ablation (CA) of persistent AF can maintain a sinus rhythm and may improve the renal function.

Purpose

We sought to elucidate whether the estimated glomerular filtration rate (eGFR) in patients with persistent AF was increased after CA, especially with the presence of an AF recurrence.

Methods

We enrolled 487 persistent AF patients whose eGFR data were available both before and 1-year after the CA out of 512 patients in the EARNEST-PVI trial.

Results

The mean age was 65±9 year and 113 patients (24.8%) had long-standing persistent AF. We compared the eGFR at baseline with that 1-year after the CA. AF recurrences were recognized in 118 patients (25.8%). The eGFR was similar between the group without recurrence and that with recurrence at baseline (without AF recurrence vs. with AF recurrence; 63.8±14.3 vs. 62.7±13.6 mL/min/1.73m2, p=0.46). In patients without AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 13 (3.8%), 198 (58.4%), 98 (28.9%), 26 (7.7%), 3 (0.9%), and 1 (0.3%), respectively at baseline. In the patients with AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 3 (2.5%), 68 (57.8%), 38 (32.2%), 6 (5.1%), 3 (2.5%), and 0 (0%), respectively at baseline. The ΔeGFR was significantly higher in the patients without AF recurrence than in those with AF recurrence (without AF recurrence vs. with AF recurrence; 5.1 [−0.3, 10.8] vs. 3.0 [−3.0, 7.6], p=0.0033). In the patients without AF recurrence, a better eGFR class at 1-year after the CA than in those before the CA was recognized in 75 patients (22.1%), while it was recognized in 19 patients (16.1%) with AF recurrences.

Conclusion

Successful catheter ablation in patients with persistent AF led to a better renal outcome.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was funded by Medtronic, Johnson & Johnson, and Abbott.

Coronary lipid-rich plaque characteristics with acute coronary syndrome and chronic coronary syndrome: a near infrared spectroscopy and intravascular ultrasound study

Background

Asians have a much lower incidence of adverse coronary events than Caucasians, and the characteristics of vulnerable plaque might be different among the ethnics.

Purpose

The aim of this study was to investigate the clinical characteristics of lipid-rich plaque (LRP) in the Asian population and we also aimed to distinguish the characteristics of an acute coronary syndrome (ACS) culprit lesion and a chronic coronary syndrome (CCS) culprit lesion. Furthermore, we evaluated the association between lipid core burden index (LCBI) and cardiovascular risk factors, lipid profiles, and inflammatory biomarkers, as determined in vivo by near infrared spectroscopy intravascular ultrasound (NIRS-IVUS) imaging in patients undergoing percutaneous coronary intervention (PCI).

Methods

We evaluated 207 patients (ACS, n=75; CCS, n=132) who underwent PCI under NIRS-IVUS. Plaque characteristics and the extent of LRP [defined as a long segment with a 4-mm maximum LCBI (maxLCBI4mm)] on NIRS in de-novo culprit and non-culprit segments were analyzed.

Results

The mean age was 65 years old and 82% of patients were male. The ACS culprit lesions had a significantly higher maxLCBI4mm (median [interquartile range (IQR)]: 533 [385–745] vs. 361 [174–527], p&lt;0.001) than the CCS culprit lesions. Whereas, no significant difference was seen in maxLCBI4mm between ACS and CCS non-culprit lesion segments (246 [53, 342] vs. 185 [37, 350], p=0.47) (Figure 1). Receiver-operating characteristic analysis showed that the NIRS maxLCBI4mm could distinguish the ACS culprit segment from the CCS culprit segment, with a sensitivity of 73% and a specificity of 69% (c-statistic = 0.69; p&lt;0.001, cut-off value of max LCBI4mm = 408) (Figure 2). On multivariate logistic analysis, a large LRP (defined as maxLCBI4mm ≥400) was the strongest independent predictor of the ACS culprit segment (odds ratio, 3.87; 95% confidence interval, 1.95–8.02). In non-culprit segments, 19.8% of patients had at least one large LRP without a small lumen. No significant correlation was found between the extent of LRP and circulating lipid profiles and inflammatory makers biomarkers (hs-CRP, IL-6, TNF-α) in both the culprit and non-culprit lesion segments, whereas the extent of LRP was positively correlated with IVUS plaque burden (r=0.24, p&lt;0.001).

Conclusions

We confirmed that NIRS-IVUS plaque assessment could be useful to differentiate ACS from CCS culprit lesions, and that a threshold maxLCBI4mm ≥400 was clinically suitable in Japanese patients. No systemic surrogate markers were found to be associated with the extent of LRP by NIRS in culprit and non-culprit segments. Consequently, we believe that direct intravascular evaluation of coronary plaque characteristics remains important for identification of high-risk LRP.

Funding Acknowledgement

Type of funding sources: None. Figure 1. The difference of maxLCBI4mmFigure 2. ROC curve

Differences in quality of life improvement with pulmonary vein isolation alone vs. more extensive ablation of persistent atrial fibrillation: insights from the EARNEST-PVI trial

Background

Improving the quality of life (QoL) is one of the main purposes of catheter ablation (CA) of persistent atrial fibrillation (AF). QoL improvement in persistent AF patients has not been fully clarified. The EARNEST-PVI trial was a multi-center randomized trial comparing clinical outcomes of pulmonary vein isolation (PVI) alone and more intensive ablation in addition to PVI including complex fractionated atrial electrogram (CFAE) and linear ablation (PVI plus).

Purpose

To investigate the QoL change after persistent AF ablation and the differences between the PVI-alone strategy and the PVI plus strategy.

Methods

In the EARNEST-PVI trial, patients with persistent AF who underwent an initial catheter ablation (n=512) were randomly assigned in a 1:1 ratio to either PVI alone or PVI plus. Quality of life was assessed at baseline and at 12 months after ablation for AF using the 36-Item Short Form Health Survey. Scores were also converted to a physical health component summary (PCS), a mental health component summary (MCS) and a role/social component summary (RCS).

Results

In the EARNEST-PVI trial, the PVI alone strategy was associated with higher recurrence rate compared with the PVI plus additional ablation strategy. After excluding 68 patients for whom preoperative or postoperative QoL assessment was not available, 222 patients were evaluated respectively. Overall, significant improvements in PCS (46.2±11.4 to 48.7±11.4]), MCS (50.1±8.8 to 54.3±8.6) and RCS (44.6±13.3 to 48.6±11.3) occurred 12 months after ablation (P&lt;0.001, respectively). Although significant QoL improvement occurred in both PVI alone and PLI plus strategies, the changes in PCS was greater in the PVI-plus than that in PVI-alone (3.5±10.3 vs 1.5±10.6, P=0.04).

Conclusions

Ablation for persistent atrial fibrillation improved both physical and mental quality of life. The PVI-plus strategy showed greater improvement in physical QoL.

Funding Acknowledgement

Type of funding sources: None. QoL improvement

A New Model for Specific Visualization of Skin Graft Neoangiogenesis Using Flt1-tdsRed BAC Transgenic Mice

BACKGROUND

Neovascularization plays a critical role in skin graft survival. Up to date, the lack of specificity to solely track the newly sprouting blood vessels has remained a limiting factor in skin graft transplantation models. Therefore, the authors developed a new model by using Flt1-tdsRed BAC transgenic mice. Flt1 is a vascular endothelial growth factor receptor expressed by sprouting endothelial cells mediating neoangiogenesis. The authors determined whether this model reliably visualizes neovascularization by quantifying tdsRed fluorescence in the graft over 14 days.

METHODS

Cross-transplantation of two full-thickness 1 × 1-cm dorsal skin grafts was performed between 6- to 8-week-old male Flt1 mice and KSN/Slc nude mice (n = 5). The percentage of graft area occupied by tdsRed fluorescence in the central and lateral areas of the graft on days 3, 5, 9, and 14 was determined using confocal-laser scanning microscopy.

RESULTS

Flt1+ endothelial cells migrating from the transgenic wound bed into the nude graft were first visible in the reticular dermis of the graft center on day 3 (0.5 ± 0.1; p < 0.05). Peak neovascularization was observed on day 9 in the lateral and central parts, increasing by 2- to 4-fold (4.6 ± 0.8 and 4.2 ± 0.9; p < 0.001). Notably, some limited neoangiogenesis was displayed within the Flt grafts on nude mice, particularly in the center. No neovascularization was observed from the wound margins.

CONCLUSION

The ability of the Flt1-tdsRed transgenic mouse model to efficiently identify the origin of the skin-graft vasculature and visualize graft neovascularization over time suggests its potential utility for developing techniques that promote graft neovascularization.

Combined impact of residual inflammatory risk and chronic kidney disease on long-term clinical outcomes in patients undergoing percutaneous coronary intervention

Background

Inflammatory status pre-percutaneous coronary intervention (PCI) and post-PCI has been reported not only associated with poor prognosis, but also to impair renal function. Statins reduce cardiovascular events by lowering lipids and have anti-inflammatory impacts, but residual inflammatory risk (RIR) exists. It remains unclear that the synergistic effect of RIR and chronic kidney disease (CKD) on long-term clinical outcome in stable coronary artery disease (CAD) patients undergoing PCI in statin era.

Aim

The aim of this study was to investigate the long-term combined impact of RIR evaluating hs-CRP at follow-up and CKD among stable CAD patients undergoing PCI in statin era.

Methods

This is a single-center, observational, retrospective cohort study assessing consecutive 2,984 stable CAD patients who underwent first PCI from 2000 to 2016. We analyzed 2,087 patients for whom hs-CRP at follow-up (6–9 months later) was available. High residual inflammatory risk was defined as hs-CRP &gt;0.6 mg/L according to the median value at follow up. Patients were assigned to four groups as Group1 (high RIR and CKD), Group2 (low RIR and CKD), Group3 (high RIR and non-CKD) or Group4 (low RIR and non-CKD). We evaluated all-cause death and major adverse cardiac events (MACE), defined as a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and non-fatal stroke.

Results

Of patients (83% men; mean age 67 years), there were 299 (14.3%) patients in group 1, 201 (9.6%) patients in group 2, 754 (36.1%) patients in group 3, and 833 (39.9%) patients in group 4. The median follow-up period was 5.2 years (IQR, 1.9–9.9 years). In total, 189 (frequency, 16.1%) cases of all-cause death and 128 (11.2%) MACE were identified during follow-up, including 53 (4.6%) CV deaths, 27 (2.4%) MIs and 52 (4.8%) strokes. The rate of all-cause death and MACE in group 1 was significantly higher than other groups (p&lt;0.001, respectively). There was a stepwise increase in the incidence rates of all-cause death and MACE. After adjustment for important covariates, the presence of high RIR and/or CKD were independently associated with higher incidence of MACE and higher all-cause mortality. (shown on figure).

Conclusion

The presence of both high RIR and CKD conferred a synergistic adverse effect on the risk for long-term adverse cardiac events in patients undergoing PCI.

Kaplan-Meier curve

Funding Acknowledgement

Type of funding source: None

Cardiac factors as well as non-cardiac factors were associated with frailty in patients with heart failure with preserved ejection fraction

Background

Frailty is associated with malnutrition and poor prognosis in patients with heart failure with preserved ejection fraction (HFpEF). However, the cardiac factors associated with frailty have not been fully examined in patients with HFpEF.

Purpose

The purpose of this study is to clarify the cardiac factors related to frailty in patients with HFpEF.

Methods

Of the 756 patients who registered prospective, multicenter, observational study of patients with HFpEF (PURSUIT-HFpEF) registry, 481 cases with clinical frailty score (CFS) and prognosis after discharge were examined. Frailty was defined as CFS ≥5. Outcomes were composite endpoint of all-cause death and heart failure readmission, and all-cause mortality. We compared outcomes between patients without and with frailty, and sought to identify factors which were associated with increase in clinical frailty score by the correlation analysis and linear regression analysis.

Results

Of 481 patients, 131 patients (27.2%) were frail. Male gender was less in patients with frailty than those without frailty (26.7% vs 73.3%, P&lt;0.001). Frail patients had higher age (85.2±7.3 vs 78.7±9.4 years, P&lt;0.001). During follow-up period of 396 [343, 697] days, composite endpoint (Kaplan-Meier event rate estimates, 77% vs. 60%; log-rank P&lt;0.001), and all-cause mortality (Kaplan-Meier event rate estimates, 57% vs. 28%; log-rank P&lt;0.001) was higher in patients with frailty than those without frailty. Multivariate Cox regression analysis revealed frailty was significantly and independently associated with mortality (HR=1.40, 95% CI=1.17–1.68, P&lt;0.001). CFS was significantly correlated with age (r=0.401, P&lt;0.001), sex (r=0.223, P&lt;0.001), body mass index (r=−0.146, P=0.001), hemoglobin (r=−0.148, P=0.001), albumin (r=−0.222, P&lt;0.001), left ventricular diastolic diameter (r=−0.184, P&lt;0.001), interventricular septum thickness (r=−0.124, P=0.008), left ventricular mass (r=−0.217, P&lt;0.001), tricuspid annular plane systolic excursion (r=−0.165, P=0.001), and tricuspid regurgitation pressure gradient (TRPG) (r=0.189, P&lt;0.001). Multivariate linear regression analysis using these factors as covariates revealed age (standardized β: 0.337, P&lt;0.001), sex (standardized β: 0.120, P=0.014), albumin (standardized β: −0.151, P=0.003) and TRPG (standardized β: 0.129, P=0.005) were significantly and independently associated with increase in clinical frailty score.

Conclusion

Our results suggest that not only nutritional factors but also a cardiac factor were associated with frailty, and frailty was associated with mortality in patients with HFpEF. Improvement of hemodynamics in HFpEF patients as well as improvement of nutrition might contribute to alleviation of frail in HFpEF patients.

Funding Acknowledgement

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

Direct Delivery of Apatite Nanoparticle-Encapsulated siRNA Targeting TIMP-1 for Intractable Abnormal Scars

Hypertrophic scars (HSs) and keloids are histologically characterized by excessive extracellular matrix (ECM) deposition. ECM deposition depends on the balance between matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteases (TIMPs). TIMP-1 has been linked to ECM degradation and is therefore a promising therapeutic strategy. In this study, we generated super carbonate apatite (sCA) nanoparticle-encapsulated TIMP-1 small interfering RNA (siRNA) (siTIMP1) preparations and examined the effect of local injections on mouse HSs and on ex vivo-cultured keloids. The sCA-siTIMP1 injections significantly reduced scar formation, scar cross-sectional areas, collagen densities, and collagen types I and III levels in the lesions. None of the mice died or exhibited abnormal endpoints. Apatite accumulation was not detected in the other organs. In an ex vivo keloid tissue culture system, sCA-siTIMP1 injections reduced the thickness and complexity of collagen bundles. Our results showed that topical sCA-siTIMP1 injections during mechanical stress-induced HS development reduced scar size. When keloids were injected three times with sCA-siTIMP1 during 6 days, keloidal collagen levels decreased substantially. Accordingly, sCA-siRNA delivery may be an effective approach for keloid treatment, and further investigations are needed to enable its practical use.

The Latest Strategy for Keloid and Hypertrophic Scar Prevention and Treatment: The Nippon Medical School (NMS) Protocol

In 2006, we established a scar/keloid-specialized unit in the Department of Plastic, Reconstructive, and Aesthetic Surgery at Nippon Medical School (NMS) in Tokyo, Japan. In the ensuing 15 years, we treated approximately 2,000 new scar/keloid patients annually. This extensive experience has greatly improved the efficacy of the treatments we offer. Therefore, we discuss here the latest NMS protocol for preventing and treating keloids and hypertrophic scars. While this protocol was optimized for Japanese patients, our experience with a growing body of non-Japanese patients suggests that it is also effective in other ethnicities. The extensive evidence-based experience underlying the NMS protocol suggests that it may be suitable as the foundation of a standard international prevention/treatment algorithm for pathological scars.

Gene Expression Profile of Isolated Dermal Vascular Endothelial Cells in Keloids

Wound healing is a complex biological process, and imbalances of various substances in the wound environment may prolong healing and lead to excessive scarring. Keloid is abnormal proliferation of scar tissue beyond the original wound margins with excessive deposition of extracellular matrix (ECM) and chronic inflammation. Despite numerous previous research efforts, the pathogenesis of keloid remains unknown. Vascular endothelial cells (VECs) are a major type of inductive cell in inflammation and fibrosis. Despite several studies on vascular morphology in keloid formation, there has been no functional analysis of the role of VECs. In the present study, we isolated living VECs from keloid tissues and investigated gene expression patterns using microarray analysis. We obtained 5 keloid tissue samples and 6 normal skin samples from patients without keloid. Immediately after excision, tissue samples were gently minced and living cells were isolated. Magnetic-activated cell sorting of VECs was performed by negative selection of fibroblasts and CD45⁺ cells and by positive selection of CD31⁺cells. After RNA extraction, gene expression analysis was performed to compare VECs isolated from keloid tissue (KVECs) with VECs from normal skin (NVECs). After cell isolation, the percentage of CD31⁺ cells as measured by flow cytometry ranged from 81.8%–98.6%. Principal component analysis was used to identify distinct molecular phenotypes in KVECs versus NVECs and these were divided into two subgroups. In total, 15 genes were upregulated, and 3 genes were downregulated in KVECs compared with NVECs using the t-test (< 0.05). Quantitative RT-PCR and immunohistochemistry showed 16-fold and 11-fold overexpression of SERPINA3 and LAMC2, respectively. SERPINA3 encodes the serine protease inhibitor, α1-antichymotripsin. Laminin γ2-Chain (LAMC2) is a subunit of laminin-5 that induces retraction of vascular endothelial cells and enhances vascular permeability. This is the first report of VEC isolation and gene expression analysis in keloid tissue. Our data suggest that SERPINA3 and LAMC2 upregulation in KVECs may contribute to the development of fibrosis and prolonged inflammation in keloid. Further functional investigation of these genes will help clarify the mechanisms of abnormal scar tissue proliferation.

Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018

There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.

P1745Clinical characteristics and long-term outcome in patients with helicopter-transported acute coronary syndrome after primary percutaneous coronary intervention

Background

Reducing delay to percutaneous coronary intervention improves functional outcome and reduces long-term mortality. Transportation by helicopter is often quicker than ground transport and thus may improve overall prognosis through reduced ischemic injury and infarction size. Our hospital is located on the medically-depopulated peninsula surrounded by mountain. The journey from the southern tip of the peninsula to the critical care medical center of our hospital take 1.5 hour by a ground ambulance but only 15 minutes by helicopter.

We compared the clinical characteristics and long-term mortality between air and ground transport of ACS patients for primary PCI.

Methods

We conducted an observational cohort study evaluating 2324 patients (mean age 68.5±12.0, male 75.2%) with ACS underwent primary PCI between April 2004 and December 2017 at our hospital.

We divided into three groups according to transportation system type (air, ground, walk-in).

The primary outcome was defined as all-cause death during the long-term follow-up.

Results

Among the entire cohort, 577 patients (24.8%) were transported by air. 1326 (57.1%) patients by ambulance, 421 (18.1%) patients by walk. Baseline characteristics were comparable, but patients by air had a higher prevalence of ST-elevation myocardial infarction.

The rate of long-term mortality was comparable during the median follow up of 6 years (air, 21.1% vs. ground, 21.4% vs. walk-in, 21.1%, respectively, log-rank p=0.72). Multivariate Cox regression analysis showed no significant association between air transportation and long-term mortality (Adjusted HR [vs ground] 1.05, 95% CI 0.60–1.78, p=0.85 and [vs walk-in] 0.94, 95% CI 0.62–1.43, respectively, p=0.77).

Kaplan-Meier curve

Conclusions

The rate of long-term mortality in patients with ACS transported by air was comparable with those transported by ground.

P5734The outcome of intra-aortic balloon pumping support for acute myocardial infarction with extracorporeal membrane oxygenation therapy

Background

It has been reported that intra-aortic balloon pumping (IABP) support for acute myocardial infarction (AMI) with cardiogenic shock did not reduce short and long-term mortality. However, the significance of IABP support for AMI patients with extracorporeal membrane oxygenation (ECMO) therapy remains unclear. The aim of this study was to investigate the effect of IABP support for the short and long-term outcome in AMI patients who received ECMO.

Methods

Using the database of the Osaka Acute Coronary Insufficiency Study (OACIS), 12,093 consecutive AMI patients were enrolled in this analysis. Among these, we analyzed 520 patients with ECMO. We classified the patients into two groups, patients who received IABP support [IABP group (n=460)] and patients who did not [no IABP group (n=60)]. Primary outcome was all-cause death.

Results

Study patients had following baseline clinical characteristics, age: 66.8±12.0 year old, male: 78.3%, diabetes mellitus: 41.0%, Killip class≥II: 66.2%, multi-vessel disease: 72.3%, peak creatine phosphokinase >3000IU/L: 68.1%. During a mean follow-up period of 349±625 days, Kaplan-Meier analysis revealed that the all-cause death was significantly lower in IABP group than no IABP group for 30-day (45.5% vs 72.7%, log-rank p<0.001) and long-term (66.2% vs 78.4%, Log rank p=0.005) follow-up period. Cox multivariate analysis revealed that IABP support was significantly associated with a reduced risk of mortality (Hazard ratio 0.445, 95% confidence interval 0.289 to 0.687, p<0.001).

Conclusions

IABP support for AMI patients with ECMO was significantly associated with reduced risks of the short and long-term mortality, suggesting that IABP support might contribute to improvement of the survival in AMI patients with ECMO.

P6173Plaque characteristics on coronary CT angiography in case of discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (IFR)

Background

The usefulness of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) evaluation has been confirmed in the determination of revascularization of coronary artery disease. When FFR≤0.8 and iFR≤0.89 were regarded as the criteria for positivity, the discordance was noted in approximately 20%, but this cause has not been well established.

Purpose

The purpose of this study was to investigate the patient background and features on coronary CT angiography (CCTA) showing the discordance between FFR≤0.8 and iFR≤0.89.

Methods

The subjects were consecutive 85 cases with 108 vessels in which stenosis of 30–90% was detected at one vessel of at least 2mm or more in the major epicardial vessels and FFR and iFR was performed within subsequent 90 days, among suspected cases of coronary arterial diseases which underwent CCTA. The factors showing the discordance between FFR and iFR (patient background, coronary artery calcification score, high risk plaque features on CCTA (positive remodeling, low attenuation plaque), plaque characteristics by a plaque analysis software using a new algorithm called labeling method (vessel volume, plaque volume, lumen volume, plaque length, maximum plaque burden, necrotic core area, fibrous area and calcium area) were evaluated using logistic regression analysis on per-patient and per-vessel basis.

Results

There were no significant both FFR and iFR positive definite factors on per-patient basis. The lumen volume/vessel volume (OR: 0.93, 95% CI: 0.88–0.98, P=0.0032) (OR: 0.90, 95% CI: 0.85–0.95, P<0.0001),minimum lumen area (MLA) (OR: 0.59, 95% CI: 0.41–0.85, P=0.0006) (OR: 0.64, 95% CI: 0.44–0.92, P=0.0047), the plaque volume/vessel volume (OR: 1.05, 95% CI: 1.01–1.10, P=0.0114) (OR: 1.09, 95% CI: 1.04–1.15, P=0.0002) and maximum plaque burden (OR: 1.08, 95% CI: 1.01–1.15, P=0.0095) (OR: 1.06, 95% CI: 1.00–1.13, P=0.0406) were significant both FFR and iFR positive definite factors on per-vessels basis. Discordance between FFR≤0.8 and iFR≤0.89 was observed in 23 vessels (21.3%) of 19 patients. In FFR positive and iFR negative group (15 vessels, 13.9%), positive remodeling (PR) (OR: 4.38, 95% CI: 1.13–17.00, P=0.0294) was only significant predictor. In FFR negative and iFR positive group, there was no significant predictors.

Conclusions

In both FFR and iFR, only lumen volume /vessel volume, MLA, plaque volume/vessel volume and plaque burden were significant positive definite factors. As for the discordance between FFR and iFR, PR is significant predictor in FFR positive and iFR negative group.

Geometric modeling and a retrospective cohort study on the usefulness of fascial tensile reductions in severe keloid surgery

BACKGROUND

Severe keloids are currently treated with surgical resection followed by radiation. Radiotherapy is essential for preventing recurrences. Fascia tensile reduction suturing may also prevent recurrence. We asked whether superficial fascia tensile reduction with or without deep fascia tensile reduction reduced skin mechanical tension and yielded good outcomes.

METHODS

Geometric modeling on 3-dimensional anatomic shapes assessed the effect of superficial fascia tensile reduction with or without deep fascia tensile reduction on skin tension. A retrospective cohort study was performed on patients with severe anterior-chest keloids with Japan Scar Workshop-scar scale classification score ≥ 16 who underwent resection plus fascia tensile reduction plus radiotherapy between 2011 and 2016 and were followed for >18 months. Patient characteristics and 18-month postoperative outcomes were examined. Postoperative outcome was defined as rates of keloid disappearance, improvement, and obvious recurrence.

RESULTS

Maximal mechanical forces placed on the dermis by dermal sutures, dermal sutures plus superficial fascia tensile reduction, and dermal sutures plus superficial fascia tensile reduction plus deep fascia tensile reduction were 4,700, 573, and 697 Pa, respectively. Adding deep fascia tensile reduction to superficial fascia tensile reduction decreased the force on the superficial fascia. Of 77 cohort patients, 27 and 50 underwent superficial fascia tensile reduction and superficial fascia tensile reduction plus deep fascia tensile reduction, respectively. Superficial fascia tensile reduction plus deep fascia tensile reduction patients underwent complete excision more often (60.0% vs 37.0%, P = .046). The groups did not differ in 18-month surgical outcome, including recurrence rate (P = .670).

CONCLUSION

Our 2003 study showed that in anterior-chest keloids, resection plus non-fascial suturing plus radiotherapy led to a 43.1% recurrence. Thus, fascia tensile reduction suturing helps reduce anterior-chest keloid recurrence to ∼5.2%. Superficial fascia tensile reduction plus deep fascia tensile reduction is suitable for relatively large keloids that require total resection. Deep fascia tensile reduction may facilitate superficial fascia tensile reduction but may only be useful when it is technically difficult to achieve reduction with superficial fascia tensile reduction alone.

Surgical excision and postoperative radiotherapy for keloids

Keloids can be treated in a number of ways, including by surgery. Multiple studies now show that while surgical monotherapy associates with extremely high rates of recurrence (50%-80%), postoperative radiotherapy can significantly reduce these recurrence rates. Ongoing improvements in radiation technology have further increased the safety and efficacy of this combination protocol. Of the various radiotherapies that have been used in this setting, electron beam (β-ray) irradiation is currently the best due to its excellent dose distribution and safety. The maximal biologically effective dose (BED) for keloids is 30 Gy (using an estimated α / β ratio of 10); increasing the dose has no further benefits and elevates side effects. Over the last two decades, we have modified and then fine-tuned our radiotherapy protocol for keloid excision wounds. Thus, our early protocol was used for all body sites and consisted of 15 Gy/3 fr/3 days. We then customised the radiotherapy protocol so that body sites that are highly prone to recurrence (e.g. the anterior chest) receive higher doses while low recurrence sites like the earlobe receive a much smaller dose. More recently, we tweaked this body site-customised protocol so that fewer fractions are employed. Therefore, we currently apply 18 Gy/3 fr/3 days to high-recurrence sites, 8 Gy/1 fr/1 day to earlobes and 15 Gy/2 fr/2 days to other body sites. These radiotherapy protocol changes were accompanied by the evolution of body site-customised surgical approaches. As a result of these developments, our overall keloid recurrence rate is now below 10%.

Long-term clinical impact of serum albumin in coronary artery disease patients with preserved renal function

BACKGROUND AND AIMS

Low serum albumin level is reportedly associated with worse clinical outcomes in patients with chronic kidney disease (CKD). However, associations between decreased serum albumin level and outcomes in non-CKD patients with coronary artery disease (CAD) remain unclear. Therefore, we aimed to evaluate the prognostic value of serum albumin concentrations in stable CAD patients with preserved renal function.

METHODS AND RESULTS

We studied 1316 patients with CAD and preserved renal function (estimated glomerular filtration rate ≥60 mL/min/1.73 m²) who underwent their first PCI between 2000 and 2011 and had data available for pre-procedural serum albumin. Patients were assigned to quartiles based on pre-procedural albumin concentrations. The incidence of major adverse cardiac events (MACE), including all-cause death and non-fatal myocardial infarction, was evaluated. Mean albumin concentration was 4.1 ± 0.4 g/dL. During the median follow-up of 7.5 years, 181 events occurred (13.8%). Kaplan-Meier curves revealed that patients with decreased serum albumin concentrations showed a higher event rate for MACE (log-rank, p < 0.0001). Using the highest tertiles (>4.3 g/dL) as reference, adjusted hazard ratios were 1.97 (95% CI, 1.12-3.55), 1.77 (95% CI, 0.99-3.25), and 1.19 (95% CI, 0.68-2.15) for serum albumin concentrations of <3.9, 3.9-4.0, and 4.1-4.3 g/dL, respectively. Decreased serum albumin concentration was associated with MACE even after adjusting for other independent variables (HR, 2.21 per 1-g/dL decrease; 95% CI, 1.37-3.56, p = 0.001).

CONCLUSION

Decreased serum albumin concentration independently predicted worse long-term prognosis in non-CKD patients after PCI. Pre-procedural serum albumin concentration could offer a useful predictor for patients with CAD and preserved renal function.

Age-associated intracellular superoxide dismutase deficiency potentiates dermal fibroblast dysfunction during wound healing

Reactive oxygen species (ROS) impair wound healing through destructive oxidation of intracellular proteins, lipids and nucleic acids. Intracellular superoxide dismutase (SOD1) regulates ROS levels and plays a critical role in tissue homoeostasis. Recent evidence suggests that age-associated wound healing impairments may partially result from decreased SOD1 expression. We investigated the mechanistic basis by which increased oxidative stress links to age-associated impaired wound healing. Fibroblasts were isolated from unwounded skin of young and aged mice, and myofibroblast differentiation was assessed by measuring α-smooth muscle actin and collagen gel contraction. Excisional wounds were created on young and aged mice to study the healing rate, ROS levels and SOD1 expression. A mechanistic link between oxidative stress and fibroblast function was explored by assessing the TGF-β1 signalling pathway components in young and aged mice. Age-related wounds displayed reduced myofibroblast differentiation and delayed wound healing, consistent with a decrease in the in vitro capacity for fibroblast-myofibroblast transition following oxidative stress. Young fibroblasts with normal SOD1 expression exhibited increased phosphorylation of ERK in response to elevated ROS. In contrast, aged fibroblasts with reduced SOD1 expression displayed a reduced capacity to modulate intracellular ROS. Collectively, age-associated wound healing impairments are associated with fibroblast dysfunction that is likely the result of decreased SOD1 expression and subsequent dysregulation of intracellular ROS. Strategies targeting these mechanisms may suggest a new therapeutic approach in the treatment of chronic non-healing wounds in the aged population.

Objective Spectrometric Measurement of Keloid Color in the East Asian Population: Pitfalls of Subjective Color Measurements

BACKGROUND

Keloids are characterized by the formation of excessive scar tissue that extends beyond the area of the initial wound. Keloid redness is due to angiogenesis and chronic inflammation and is an important indicator of the severity of the lesion and the effectiveness of treatment.

METHODS

The color of 33 untreated keloids from 30 patients was measured with a narrow-band reflectance colorimeter. The erythema and melanin levels in the keloids (Ek and Mk, respectively) were recorded with control data obtained from the flexor aspect of the forearm (Ec and Mc, respectively). The keloid color was also evaluated subjectively.

RESULTS

The Ek or Mk values did not vary significantly according to symptom intensity, scar region, patient age, and patient sex. Younger patients (<40 years) and female patients had significantly higher Ek/Ec ratios than did older patients and male patients, respectively. Subjective keloid redness evaluations distinguished keloids with high Ek/Ec ratios from keloids with low Ek/Ec ratios (P<0.0001) but could not distinguish keloids with high Ek from keloids with low Ek.

CONCLUSIONS

Subjective evaluations of keloids in Japanese subjects reflected Ek/Ec ratios, which were strongly affected by variation in background skin color. The subjective assessment of the color of keloids or other skin disorders should be performed with caution in Asian populations.