Appropriate assessment using virtual reality simulation for a novel reshaped curve sheath during percutaneous left atrial appendage closure: a follow-up case report

Background

We previously reported a case of successful percutaneous left atrial appendage closure (LAAC) for complex left atrial appendage (LAA) morphology using a handmade double-curve delivery sheath (DS) reshaped by a heat gun. However, whether the reshaped curve was appropriately adjusted as an optimal configuration for this patient's anatomy remained uncertain.

Case summary

We established the LAAC procedural simulation model supported by virtual reality (VR) technology. With this VR simulator, the patient's whole heart model with venous access route and atrial septal puncture point of foramen ovale (FO) could be replicated based on the pre-procedural computed tomography image. Multiple views of the VR image provided a deep understanding of the patient-specific anatomy. Additionally, the operators were enabled to perform the virtual LAAC procedure using VR-derived LAAC devices, including various DS types. In the VR simulator, the manually reshaped DS showed better co-axiality from the FO to the LAA orifice than the conventional double-curve DS, resulting in the successful deployment inside the LAA of the VR simulator. However, the perpendicularity of the device towards the LAA orifice of the handmade reshaped DS remained insufficient. The VR simulator suggested that the ideal curve of the DS needed to change relatively posteriorly and have a more aggressive inferior slide than the previously reshaped DS.

Discussion

The post-procedural review of the VR simulator confirmed that the sheath reshaping technique helped ensure successful LAAC. Pre-procedural VR simulation may be useful for procedural planning that includes DS reshaping for patients with challenging anatomy undergoing LAAC.

Ramucirumab plus FOLFIRI as second-line treatment for patients with RAS wild-type metastatic colorectal cancer previously treated with anti-EGFR antibody: JACCRO CC-16

BACKGROUND

Chemotherapy in combination with anti-epidermal growth factor receptor (EGFR) antibody is considered a first-line treatment regimen for RAS wild-type and left-sided metastatic colorectal cancer (mCRC), whereas second-line treatment regimens have not yet been established. Few studies have prospectively evaluated second-line treatment with anti-vascular endothelial growth factor antibody after first-line anti-EGFR antibody therapy for RAS wild-type mCRC.

PATIENTS AND METHODS

This non-randomized phase II trial investigated the clinical outcomes of second-line ramucirumab (RAM) plus fluorouracil, levofolinate, and irinotecan (FOLFIRI) after first-line anti-EGFR antibody in combination with doublet or triplet regimen in patients with RAS wild-type mCRC. The primary endpoint was the 6-month progression-free survival (PFS) rate. The secondary endpoints were PFS, overall survival (OS), objective response rate (ORR), rate of early tumor shrinkage (ETS), and safety. We hypothesized a threshold 6-month PFS rate of 30% and an expected 6-month PFS rate of 45%. Treatment was considered effective if the lower limit of the 90% confidence interval (CI) of the 6-month PFS rate was >0.30.

RESULTS

Ninety-two patients were enrolled in the study. The primary tumor was located on the left side in 86 (95.6%) patients. Twenty (22.0%) patients had received triplet plus cetuximab as previous therapy. Six-month PFS rate was 58.2% (90% CI 49.3% to 66.2%) with a median PFS of 7.0 months (95% CI 5.7-7.6 months). Median OS was 23.6 months (95% CI 16.5-26.3 months). The ORR and ETS rate were 10.7% and 16.9%, respectively, in 83 patients with measurable lesions. The 6-month PFS rate was comparable between patients previously treated with doublet and triplet regimens; however, median PFS was longer for the doublet regimen (7.4 versus 6.4 months, P = 0.036).

CONCLUSIONS

Our study demonstrated prospectively that RAM plus FOLFIRI is an effective second-line treatment after anti-EGFR antibody-containing first-line therapy in RAS wild-type and left-sided mCRC. Furthermore, the results were similar for patients who were previously treated with triplet regimen.

Incidence, Timing, and Causes of Late Bleeding After TAVR in an Asian Cohort

BACKGROUND

Data regarding the incidence, predictive factors, and clinical outcomes of post-transcatheter aortic valve replacement (TAVR) bleeding is limited in the Asian cohort.

OBJECTIVES

This study sought to assess the predictors and prognostic impact of post-TAVR late bleeding.

METHODS

This study used the Japanese multicenter registry data to analyze 2,518 patients (mean age: 84.3 ± 5.2 years) who underwent TAVR. Late bleeding was defined as any postdischarge bleeding events after TAVR. Baseline characteristics, predictive factors, and clinical outcomes including death and rehospitalization were assessed in patients with and without late bleeding events.

RESULTS

The cumulative incidence rate of all and major late bleeding and ischemic stroke were 7.4%, 5.2%, and 3.4%, respectively, 3 years after TAVR. The independent predictive factors of late bleeding were low platelet count, high score (≥4) on the clinical frailty scale, and a New York Heart Association functional class III/IV. The cumulative mortality rates up to 3 years were significantly higher in patients with late bleeding than in those without bleeding (P < 0.001). The multivariate Cox regression analysis revealed that late bleeding, included as a time-varying covariate in the model, was associated with an increased risk of mortality following TAVR (HR: 5.63; 95% CI: 4.28-7.41; P < 0.001).

CONCLUSIONS

Late bleeding after TAVR was not a rare complication, and it significantly increased long-term mortality. It should be carefully managed, especially when it is predictable in the high-risk cohort, and efforts should be taken to reduce bleeding complications even after a successful procedure.

ACTIVATION OF HUMAN FIBROBLASTS BY CHRONIC RADIATION RATHER THAN ACUTE RADIATION

Cancer-associated fibroblast (CAF), an activated type of fibroblast, is a major stromal cell that contributes to tumor initiation and development in the tumor microenvironment (TME). We previously reported that fractionated radiation rather than acute radiation causes progressive damage to mitochondria and increases the generation of reactive oxygen species, playing an important role in the fibroblast activation in normal tissue injury. Activated fibroblasts then become CAF by interacting with tumor cells, promoting tumor growth in vivo. We here examined the chronic radiation effect on fibroblast activation. Acute radiation (<2.5 Gy) did not increase alpha-Smooth muscle actin, a CAF marker expression in healthy human cells, whereas chronic radiation (2.5 Gy) did. It can be concluded that the induction of fibroblast activation changes across acute radiation, fractionated radiation, and chronic radiation depending on the irradiation technique. This study highlights that radiation activates fibroblasts, playing a role in radiation-related tumor development via TME formation.

Transcatheter aortic valve implantation and frailty

Over the last decade, transcatheter aortic valve implantation (TAVI) has emerged as a treatment option for patients with severe aortic stenosis. With exponential increase in the number of TAVI procedures, frailty assessments have been considered important for patients undergoing TAVI, and a number of studies have indicated a relationship between the frailty and post-TAVI outcomes. In this review, using studies searched systematically in the PubMed database, we review important frailty assessment tools that can be used as prognostic factors for patients before TAVI. The assessment tools were categorized as quantitative single marker, semi-quantitative single marker, or quantitative combined marker. Studies were further stratified by whether they used frailty markers to predict patients' prognosis pre-TAVI or to evaluate frailty improvement post-TAVI. The Clinical Frailty Scale (CFS), a semi-quantitative assessment, is one of the frailty assessment tools discussed. It may be easily used even in an outpatient consultation room. The CFS classifies patients' activity into nine categories, based on a simple interview and the patient's appearance. Gait speed and serum albumin levels were considered as qualitative frailty assessment tools. Compared to other methods, the Essential Frailty Toolset had the highest inter-rater reliability for accuracy in predicting mortality, thereby allowing better identification of vulnerable old age people and optimization of outcomes. A few studies have also focused on changes in frailty pre- and post-TAVI. Serum albumin-level measurements are important for assessing the frailty improvement in the chronic phase. Each frailty assessment tool had its own characteristics, strengths, and weaknesses, and therefore, these tools need to be selected based on where they are being used and the patient's condition.

A global ensemble of ocean wave climate statistics from contemporary wave reanalysis and hindcasts

There are numerous global ocean wave reanalysis and hindcast products currently being distributed and used across different scientific fields. However, there is not a consistent dataset that can sample across all existing products based on a standardized framework. Here, we present and describe the first coordinated multi-product ensemble of present-day global wave fields available to date. This dataset, produced through the Coordinated Ocean Wave Climate Project (COWCLIP) phase 2, includes general and extreme statistics of significant wave height (H_s), mean wave period (T_m) and mean wave direction (θ_m) computed across 1980–2014, at different frequency resolutions (monthly, seasonally, and annually). This coordinated global ensemble has been derived from fourteen state-of-the-science global wave products obtained from different atmospheric reanalysis forcing and downscaling methods. This data set has been processed, under a specific framework for consistency and quality, following standard Data Reference Syntax, Directory Structures and Metadata specifications. This new comprehensive dataset provides support to future broad-scale analysis of historical wave climatology and variability as well as coastal risk and vulnerability assessments across offshore and coastal engineering applications.

Measurement(s)	Significant wave height • Mean wave period • Mean wave direction
Technology Type(s)	Global wave reanalysis and hindcasts
Sample Characteristic - Environment	Wind-waves
Sample Characteristic - Location	Global

P–193 First cleavage division perpendicular to the pronuclear axis adversely affects the clinical outcome in human embryos

Study question

Does the direction of formation for the first cleavage plane relative to the pronuclear axis affect clinical outcome?

Summary answer

A first cleavage division perpendicular to the pronuclear axis adversely affects the rate of embryo utilization for transfer or cryopreservation and the pregnancy outcome.

What is known already

It remains unclear how the first cleavage plane is determined in human embryos. By using time-lapse monitoring, our previous study (presented in ESHRE 2019) suggested that both the axis and locations of male and female pronuclei are involved in determining the first embryonic cleavage plane. Furthermore, by using immunofluorescence analysis, it was also revealed that most analyzed zygotes showed two pericentrin signals aligned around the interface between the male and female pronuclei. Our findings suggest that the pronuclear axis strongly influences the positions of the centrosomes, which become mitotic spindle poles and define the first cleavage plane. Study design, size, duration: From January 2015 to December 2017, time-lapse imaging (EmbryoScope®) of 3397 intracytoplasmic sperm injection (ICSI) oocytes was conducted. Of those, the relationship between the pronuclear axis and the first cleavage plane was analyzed in 607 normally fertilized embryos that cleaved to two cells and were obtained in 2015. Furthermore, of 3397 ICSI oocytes, 749 transferred embryos were classified based on the first cleavage patterns relative to the pronuclear axis, and the pregnancy rate was examined.

Participants/materials, setting, methods

A straight line connecting the centers of the pronuclei was defined as the 2PN axis. Based on the direction of the first cleavage relative to the 2PN axis, embryos were classified into three groups: parallel, perpendicular and intermediate. Fresh embryos were transferred on Day 2/3 (fresh-ET). Frozen and thawed embryos were transferred on Day 2/3 or Day 5 (F/T-ET). Clinical pregnancy was defined as confirmed gestational sac in the uterine cavity.

Main results and the role of chance

Of 607 analyzed embryos, 506 produced suitable images and were assigned to one of three groups: parallel (84.4%, n = 427), perpendicular (9.7%, n = 49) and intermediate (5.9%, n = 30). Embryos that formed a cleavage furrow parallel to the 2PN axis were significantly more frequent than others (perpendicular, intermediate) (P &lt; 0.001). The embryo utilization rate for transfer or cryopreservation was significantly lower in the perpendicular group than in the parallel group (30.7% vs. 69.3%, P &lt; 0.01). Furthermore, of 749 transferred embryos, 504 assigned to the parallel and perpendicular groups were selected (n = 470 and n = 34, respectively), and the pregnancy outcome was analyzed. The mean maternal age was not significantly different between groups. The pregnancy rate of embryos was 24.2% (n = 45/186) from fresh-ET and 39.4% (n = 112/284) from F/T-ET in the parallel group, and 0% (n = 0/14) from fresh-ET and 15.0% (n = 3/20) from F/T-ET in the perpendicular group. Regardless of the types of embryo transfer (fresh or F/T), the pregnancy rate was significantly lower in the perpendicular group than in the parallel group (P &lt; 0.01). In addition, one of three patients who became pregnant from the transfer of an embryo in the perpendicular group had a miscarriage.

Limitations, reasons for caution

Since only ICSI embryos were analyzed in this study, the influence of fertilization methods on subsequent development could not be investigated. Further studies including preimplantation genetic testing for aneuploidy may help determine the reasons why pregnancy rates differ between groups.

Wider implications of the findings: We suggest that the 2PN axis is essential for determining the first cleavage plane because it seems to be involved in positioning the mitotic spindle poles. The direction of the first cleavage plane relative to the 2PN axis can be an important indicator for predicting embryo development and pregnancy outcome

Trial registration number

none

P–215 The degree of perivitelline space (PS) at the pronuclear stage affects subsequent embryonic development in human zygotes

Study question

Was embryonic development affected by the degree of perivitelline space (PS) at the pronuclear stage in human zygotes?

Summary answer

Zygotes with a fully surrounding PS showed less cytoplasmic fragmentation and a higher blastocyst development rate (BDR) than zygotes with a partially surrounding PS.

What is known already

We previously used abnormally-fertilized oocytes (zygotes with three pronuclei; 3PN), donated by ART patients in our clinic who gave written consent for the research. The zona pellucida (ZP) was artificially removed from these oocytes at the pronuclear stage, termed ZP-free culture. The resultant ZP-free 3PN embryos showed less cytoplasmic fragmentation and a higher rate of good-quality embryos (GQE) compared with ZP-intact embryos. Furthermore, in our clinical setting, the rate of GQE and BDR of normally-fertilized embryos were clearly improved by ZP-free culture in patients with recurrent failure of ART treatments due to severe cytoplasmic fragmentation at the early cleavage stage.

Study design, size, duration

This study included 49 patients who gave written informed consent for our study and were treated with ART in our clinic between March and December 2020. Embryonic development was compared between zygotes with a fully surrounding PS [PS(+)] with those with a partially surrounding PS [PS(-)] at the pronuclear stage. Furthermore, the ZP of PS(-) embryos were artificially removed at the pronuclear stage, and the rate of GQE and BDR were compared with ZP-intact embryos.

Participants/materials, setting, methods

The degree of PS in 128 zygotes was confirmed by hypertonic preparation using 0.125M sucrose-containing HEPES medium. PS(+) and PS(-) embryos were both cultured as ZP-intact, and the rate of GQE was compared. Furthermore, 223 zygotes were divided into three groups: 1) PS(-)/ZP-intact, 2) PS(-)/ZP-free, and 3) PS(+)/ZP-intact, and cultured in an incubator equipped with time-lapse monitoring up to Day 7, and the rate of GQE, BDR and useable embryos were compared between each groups.

Main results and the role of chance

The degree of PS was confirmed by a hypertonic preparation (shrinkage of the ooplasm) in 128 normally-fertilized zygotes obtained from 44 cases. There were 86 PS(-) (67.2%) and 42 PS(+) (32.8%) zygotes. The mean maternal age was 35.9 in PS(-) and 40.5 in PS(+) (P &lt; 0.01), and the rate of GQE was significantly higher in PS(+) [64.3% (27/42)] than in PS(-)[38.4% (33/86)] (P &lt; 0.01). In addition, of 223 normally-fertilized zygotes obtained from 41 cases, there were 51 PS(-)/ZP-intact (Group 1), 132 PS(-)/ZP-free (Group 2) and 40 PS(+)/ZP-intact (Group 3) zygotes. The rate of GQE was significantly lower in Group 1 [29.4% (15/51)] compared with Group 2 [59.8% (79/132)] and Group 3 [62.5% (25/40)] (P &lt; 0.01). BDR was also significantly lower in Group 1 [51.3% (10/39)] compared with Group 2 [75.0% (99/132)] and Group 3 [65.0% (13/20) (P &lt; 0.01).

Limitations, reasons for caution

Although the artificial removal of ZP at the pronuclear stage (ZP-free culture) clearly increased the rate of GQE, embryonic development was not improved in all cases. It seems that this procedure is only effective in embryos with a viable ooplasm.

Wider implications of the findings: The degree of PS at the pronuclear stage affects subsequent embryonic development in human zygotes. The artificial removal of ZP at the pronuclear stage (ZP-free culture) helps to suppress fragmentation and leads to an increase in GQE and BDR, and eventually, improves pregnancy rate in cases with severe fragmentation.

Trial registration number

non

P–201 The beneficial effects of ZP-free culture on cytoplasmic fragmentation in human embryos. : An innovative trial using 3PN zygotes

Study question

Is it possible to culture ZP-free embryos to eliminate perivitelline threads, which are known to be involved in generating cytoplasmic fragments at the first cleavage?

Summary answer

ZP-free culturing, an innovative system that decreases the amount of cytoplasmic fragments without disrupting the blastomeres, using incubators with time-lapse imaging.

What is known already

A study in 2017 observed perivitelline threads in more than 50% of cleavage-stage human embryos using time-lapse imaging, and the rate of cytoplasmic fragmentation (at the first cleavage) was significantly decreased in embryos without perivitelline threads (P &lt; 0.001). While it has been proposed that perivitelline threads play an important role in crosslinking the cumulus cells and oocyte during maturation, the mechanism underlying such a role remains unclear. It is also unknown whether the threads still function in mature MII oocytes.

Study design, size, duration

A prospective study was conducted using 2,852 normal (2PN/2PB) embryos from c-IVF/ICSI and 113 abnormal (3PN) embryos obtained from c-IVF between 2017 and 2019. The zona pellucida (ZP) of 71 abnormal embryos was removed at the pronuclear stage (“ZP-free”), and the rest (n = 42) were cultured as “ZP-intact”. Normal and abnormal embryos were cultured for five days in bench-top incubators (MINC, COOK) and an incubator equipped with a time-lapse imaging system.

Participants/materials, setting, methods

Embryos used in this study were donated by 412 couples who underwent c-IVF cycles in our clinic between 2017 and 2019. For ZP removal, 3PN embryos were placed in 0.125M sucrose-containing HEPES media drops to reduce the ooplasm size. Then, ooplasms were completely separated from ZPs by a laser and pipetting. Embryo development and morphology of the three groups (normal, ZP-intact and ZP-free abnormal) were compared based on the degree of cytoplasmic fragmentation.

Main results and the role of chance

The first cleavage occurred in 97.8% (n = 2,790/2,852) of 2PN/2PB, 83.3% (n = 35/42) of ZP-intact 3PN and 97.2% (n = 69/71) of ZP-free 3PN. Normal (2PN/2PB), ZP-intact and ZP-free 3PN embryos were classified into three groups based on the modified Veeck’s criteria thus: &lt;20% fragmented compared to the total volume of cytoplasm at the first cleavage (Grade 1 and 2, Good); 20–39% fragmented (Grade 3, Fair) and ≧40% fragmented (Grade 4, Poor). Of 69 cleaved ZP-free 3PN embryos, 68.1% (n = 47) showed less than 20% fragments which was significantly higher than 2PN/2PB (43.7%, n = 1,218/2,790) and ZP-intact 3PN (45.7%, n = 16/35; P &lt; 0.05). Furthermore, 24.6% (n = 17/69) of ZP-free 3PN embryos showed 20–39% fragments which was significantly lower than 2PN/2PB (45.9%, n = 1,281/2,790; P &lt; 0.05). In addition, 50.7% of ZP-free 3PN embryos (n = 36) developed to the morula stage after the third cleavage, and 29.6% (n = 21) formed blastocoel and became blastocysts. Thus, removing the ZP before the first cleavage did not adversely affect embryo development and decreased the cytoplasmic fragmentation.

Limitations, reasons for caution

Due to ethical and clinical limitations, we only examined abnormally fertilized embryos in this study. Moreover, since the relationship between the perivitelline threads and cytoplasmic fragments is unclear, we plan to conduct molecular biological analysis of the perivitelline threads in further studies.

Wider implications of the findings: This study revealed that ZP is not always necessary after the pronuclear stage because ZP-free embryos studied herein developed normally and maintained cell adhesion well. This innovative culture method might provide the breakthrough needed for patients to improve embryo quality who obtain embryos with severe fragmentation caused by perivitelline threads.

Trial registration number

Not applicable

O-219 Detailed morpho-kinetic analysis of the first cleavage can help in evaluating the viability of direct-cleaved human zygotes

Study question

Why do some direct-cleaved human zygotes still lead to a live birth?

Summary answer

Direct-cleaved zygotes which have undergone the 2-cell stage can lead to a live birth, while zygotes cleaved from 1-cell to ≥ 3-cell do not.

What is known already

In recent years, zygotes that develop from 2-cell to 3-cell within 5 hours after the first cleavage have been evaluated as “direct-cleaved” zygotes, because normal cleavage takes approximately 12 hours to complete. It was reported that their implantation rate was significantly lower than zygotes with normal cleavage pattern, and eliminating direct-cleaved zygotes from transfer could improve the implantation rate. However, some direct-cleaved zygotes at the first cleavage could still lead to a live birth. Few reports have examined the difference between a cleavage from 1-cell to ≥ 3-cell and 2-cell to ≥ 3-cell within 5 hours after the first cleavage.

Study design, size, duration

A retrospective study involving 2,077 cycles of IVF/ICSI between July 2012 and July 2019. A total of 5,991 normally fertilized zygotes (2PN/2PB) were included. Of those, 3,508 were evaluated as usable good/fair quality embryos on Day2/3, and the rest (n = 2,483) were evaluated as poor quality and rejected from transfer or cryopreservation after 7 days of culture. Of 3,508 usable embryos, 884 were selected based on the availability of results of live birth for this study.

Participants/materials, setting, methods

Time-lapse imaging (5 slices along Z-axis every 10 minutes) was performed in EmbryoScopeTM. Zygotes were morphokinetically analyzed in detail and classified into four groups by their cleavage patterns: Group1 (1-cell→2-cell); Group 2 (1-cell→3-cell); Group 3 (1-cell→2-cell→≥3-cell within 5 hours after the first cleavage); and Group 4 (1-cell→2-cell→≥5-cell). The proportion, mean maternal age and live birth rate of each group were examined.

Main results and the role of chance

The proportion of Groups 1-4 was 83.6% (n = 739), 3.8% (n = 34), 5.9% (n = 52), and 6.7% (n = 59), respectively. 0f 884 zygotes examined in this study, the mean maternal age was significantly higher in Group 2 and 4 than in Group 1 (P &lt; 0.05; 37.4±4.9 in Group1, 39.1±5.2 in Group 2, 38.6±6.0 in Group 3, and 38.7±5.1 in Group 4). The rate of confirmed gestational sac was significantly lower in Group 2 and 4 than in Group 1 [P &lt; 0.01; 36.3% (n = 268/739), 0% (n = 0/34), 25.0% (n = 13/52), and 18.6% (n = 11/59) in Groups 1-4, respectively]. Furthermore, the live birth rate was significantly higher in Group 1 than in Groups 2, 3 and 4 [P &lt; 0.01; 28.4% (n = 210/739), 0% (n = 0/34), 13.5% (n = 7/52), and 15.3% (n = 9/59) in Groups 1-4, respectively]. Above all, while zygotes in Group 2 showed no pregnancy and live birth at all, zygotes in Group 3 showed a live birth rate of 13.5%. However, they had a significantly higher miscarriage rate (42.9%, n = 6) compared to zygotes in Group 1 (19.5%, n = 55).

Limitations, reasons for caution

It is very difficult to capture cleavage patterns by routine observations because the timings of developmental events are different between embryos. A time-lapse imaging and culturing system is essential to solve this problem, however, it cannot visualize the distribution of chromosomes, and no chromosomal analysis was conducted in this study.

Wider implications of the findings

This study revealed that zygotes previously classified as “direct-cleaved” and eliminated from transfer included viable zygotes which could lead to a live birth. Therefore, it is crucial to optimize the use of time-lapse imaging of human zygotes in order to precisely evaluate the first cleavage.

Trial registration number

not applicable

P–216 Successful pregnancies and deliveries in patients with a recurrent failure of ART treatments following artificial removal of the zona pellucida (ZP) at the pronuclear stage

Study question

Can a novel embryo culture method that artificially removes the ZP at the pronuclear stage yield successful pregnancy in patients with poor-quality embryos and/or blastocysts?

Summary answer

A blastocyst transfer after ZP-free culture can result in pregnancy for patients who cannot obtain good quality blastocysts from conventional culture methods.

What is known already

Perivitelline threads are been associated with the formation of cytoplasmic fragments. We had previously observed perivitelline threads in the adhesive region between the ooplasm and the ZP at the first cleavage in human embryos. We removed the ZP at the pronuclear stage in 71 abnormally fertilized oocytes (zygotes with three pronuclei), donated after conventional IVF (c-IVF), and termed them ZP-free 3PN. We found ZP-free 3PN embryos could be cultured without losing blastomere adhesions. Furthermore, the rate of good quality embryos was significantly higher in ZP-free 3PN embryos compared with ZP-intact embryos (ZP-intact 2PN/2PB and 3PN embryos; P &lt; 0.05).

Study design, size, duration

This study was conducted in two cases selected among patients who underwent ART treatment in our clinic between 2018 and 2019. Cases were selected if they lacked good quality blastocysts in previous c-IVF/Intracytoplasmic Sperm Injection (ICSI) cycles due to massive cytoplasmic fragmentation at the first and second cleavage. We performed a clinical trial of ZP-free culture from December 2019 to March 2020.

Participants/materials, setting, methods

Two cases were selected for this trial. Normally fertilized oocytes were grouped as ZP-free or ZP-intact. For the ZP-free group, 2PN embryos were placed in 0.125M sucrose-containing HEPES to reduce ooplasm size, then ooplasms were completely separated from ZPs by a laser and pipetting. ZP-free and ZP-intact embryos were cultured with time-lapse imaging for up to seven days. Resultant blastocysts were either transferred into uterus or cryopreserved on Day5/6/7 for future embryo transfer cycles.

Main results and the role of chance

The ZP-free culture method was applied to two patients (patient A and B) with recurrent failure of ART in our clinic due to poor-quality embryos and/or difficulties in obtaining good quality blastocysts. In both cases, blastocysts were successfully obtained and cryopreserved for all ZP-free culture cycles. In patient A, one good quality ZP-free blastocyst was freshly transferred five days after oocyte retrieval, and a live male baby (2925g) was delivered at 40 weeks of gestation by caesarean section). In patient B, a frozen/thawed ZP-free blastocyst transfer was conducted, and a live female baby (3225g) was delivered at 39 weeks of gestation by vaginal delivery. This shows ZP-free culturing may help obtain viable embryos in patients for which conventional in vitro culturing methods result in embryos characterized with severe cytoplasmic fragmentation and poor quality in the early cleavage stage.

Limitations, reasons for caution

Although successful pregnancies and deliveries were confirmed in two cases, postnatal evaluations will be absolutely necessary for infants derived from ZP-free culture. In addition, the number of trial cases needs to be expanded, however careful selection of suitable patients is necessary for this novel culture method.

Wider implications of the findings: We found removing the ZP at the pronuclear stage improved embryo development and led to successful pregnancies and deliveries after blastocyst transfer. This indicates ZP-free culturing may be an effective method for decreasing cytoplasmic fragmentation caused by perivitelline threads or adhesion between the ooplasm and the zona pellucida.

Trial registration number

Not applicable

Late kidney injury after transcatheter aortic valve replacement

BACKGROUND

Information on early to late-phase kidney damage in patients who underwent transcatheter aortic valve replacement (TAVR) is scarce. We aimed to identify the predictive factors for late kidney injury (LKI) at 1-year and patient prognosis beyond 1-year after TAVR.

METHODS

We retrospectively reviewed 1,705 patients' data from the Japanese TAVR multicenter registry. Acute kidney injury (AKI) and LKI, defined as an increase of at least 0.3 mg/dL in creatinine level, a relative 50% decrease in kidney function from baseline to 48 hours and 1-year, were evaluated. The patients were categorized into the 4 groups as AKI-/LKI- (n = 1.362), AKI+/LKI- (n = 95), AKI-/LKI+ (n = 199), and AKI+/LKI+ (n = 46).

RESULTS

The cumulative 3-year mortality rates were significantly increased across the four groups (12.5%, 15.8%, 24.6%, 25.8%, P < .001). Multivariate analysis revealed that chronic kidney disease, coronary artery disease, periprocedural AKI, and heart failure-related re-admission within 1-year were significantly associated with LKI. The Cox regression analysis revealed that AKI-/LKI+ and AKI+/LKI+ were independent predictors of increased late mortality beyond 1-year after TAVR (P = .001 and P = .01).

CONCLUSIONS

LKI was influenced by adverse cardio-renal events and was associated with increased risks of late mortality beyond 1-year after TAVR.

Calculated plasma volume status and outcomes in patients undergoing transcatheter aortic valve replacement

Aims

This study investigated the prognostic value of plasma volume status (PVS) in patients who underwent transcatheter aortic valve replacement (TAVR).

Methods and results

Plasma volume status was calculated in 2588 patients who underwent TAVR using data from the Japanese multicentre registry. All‐cause mortality and heart failure hospitalization (HFH) within 2 years of TAVR were compared among the PVS quartiles (Q1, PVS < 5.5%; Q2, PVS 5.5–13.5%; Q3, PVS 13.5–21.0%; and Q4, PVS ≥ 21.0%). Subgroups were stratified by the PVS cut‐off value combined with the New York Heart Association (NYHA) class as follows: low PVS with NYHA I/II (n = 959), low PVS with NYHA III/IV (n = 845), high PVS with NYHA I/II (n = 308), and high PVS with NYHA III/IV (n = 476). The cumulative all‐cause mortality and HFH within 2 years of TAVR significantly increased with increasing PVS quartiles [8.5%, 16.8%, 19.2%, and 27.0% (P < 0.001) and 5.8%, 8.7%, 10.3%, and 12.9% (P < 0.001), respectively]. The high‐PVS group regardless of the NYHA class had a higher all‐cause mortality and HFH [9.6%, 18.2%, 24.5%, and 30.4% (P < 0.001) and 6.1%, 10.4%, 14.1%, and 11.3% (P < 0.001)]. In a Cox regression multivariate analysis, the PVS values of Q3 and Q4 had independently increased all‐cause mortality [hazard ratio (HR), 1.50 and 1.64 (P = 0.017 and P = 0.008), respectively], and Q4 had independently increased HFH (HR, 1.98, P = 0.005). The low PVS with NYHA III/IV, high PVS with NYHA I/II, and high PVS with NYHA III/IV also had significantly increased all‐cause mortality [HR, 1.45, 1.73, and 1.86 (P = 0.006, P = 0.002, and P < 0.001), respectively] and HFH [HR, 1.52, 2.21, and 1.70 (P = 0.049, P = 0.002, and P = 0.031), respectively].

Conclusions

Plasma volume status is useful for predicting all‐cause mortality and HFH after TAVR.

Incidence and Predictive Factors of Chronic Vessel Enlargement After Percutaneous Coronary Intervention for Severely Stenotic and Occluded Lesions

BACKGROUND

Chronic vessel enlargement (CVE) of the coronary artery is observed in patients who undergo percutaneous coronary intervention (PCI) for severely stenotic or occluded lesions. Recently, the presence of a peri-medial high-echoic band (PHB) identified by intravascular ultrasound (IVUS) has been reported to correlate with this phenomenon. We sought to assess the incidence, predictive factors of CVE, and association between CVE and PHB.

METHODS

From January 2017 to December 2018, 97 patients, with 101 severely stenotic and occluded lesions, who underwent IVUS-guided PCI and a 9-month follow-up angiography were enrolled. CVE was defined as more than a 10% increase of distal lumen gain at follow-up angiography. All lesions were stratified into 2 groups: CVE group and non-CVE group. Clinical outcomes were compared and predictive factors for CVE were assessed. Relationships between PHB angle and CVE were also assessed.

RESULTS

At follow-up angiography, CVE was observed in 27 lesions (26.7%, 27/101). PHBs were frequently observed in the CVE group (88.9%), which was significantly higher than that in the non-CVE group (40.5%). The multivariate logistic regression analysis revealed that the presence of PHB was the only predictive factor for CVE (odds ratio, 11.3; 95% confidence interval, 2.95-43.0; p < 0.001). In addition, a linear relationship was observed between the incidence of CVE and PHB angle. The number of patients with CVE significantly increased in cases with a PHB angle more than 180 degrees.

CONCLUSIONS

The presence of PHB strongly predicts CVE after PCI for severely stenotic or occluded lesions.

Current status of hybrid intravascular ultrasound and optical coherence tomography catheter for coronary imaging and percutaneous coronary intervention

Both intravascular ultrasound (IVUS) and optical coherence tomography (OCT) play a crucial role in elucidating the pathophysiology of coronary artery disease (CAD) with the goal to improve patient outcomes of medical and/or interventional CAD management. However, no single intravascular imaging technique has been proven to provide complete and detailed evaluation of all CAD lesions due to some limitations. Although sequential use of multiple modalities may sometimes be performed, there may be issues related to risk, time, and cost. To overcome these problems, several hybrids involving dual-probe combined IVUS-OCT catheters have been developed. The aim of this review article is to demonstrate some limitations of stand-alone imaging devices for evaluation of CAD, summarize the advances in hybrid IVUS-OCT imaging devices, discuss the technical challenges, and present the potential value in the clinical setting, especially in patients receiving medical or interventional CAD management.

Statins bring the prognostic impact only in peripheral artery disease patients with elevated c-reactive proteins -subanalysis from multicenter registry-

Introduction

Recent trials demonstrated favorable effects of statins on the clinical prognosis, partly through anti-inflammatory properties, in patients with coronary artery disease. However, this favorable effect has not been fully verified in patients with peripheral arterial disease (PAD). We hypothesized that statins exert different prognostic effects depending on the degrees of inflammation at the time of endovascular therapy (EVT).

Methods

This study is a subanalysis from the Toma-Code Registry that is a Japanese prospective cohort of 2,321 consecutive patients with PAD treated by endovascular therapy in hospitals from 2014 to 2016. After the exclusion of patients without information of C-reactive protein (CRP) at the time of index EVT, 2,039 patients including 1,039 statin users and 1,000 statin non-users were ultimately analyzed. The patient enrolled were divided into 4 categories depending on CRP level at the time of EVT; Low-CRP (&lt;0.1 mg/dL), Intermediate-low-CRP (0.1–0.3 mg/dL), Intermediate-High-CRP (0.3–1.0 mg/dL), and High-CRP (&gt;1.0 mg/dL). A composite of death, stroke, myocardial infarction, and major amputation as the primary endpoint of this study was compared between statin users and non-users in each CRP category.

Results

The composite endpoint occurred in 255 patients during the observation period. Overall, statin users had a significantly lower event rate than non-users (Log-rank test: P&lt;0.001). However, there were no significant difference in the event rates between statin users and non-users in the Low-, and Intermediate-Low-CRP categories. Only in the Intermediate-High- and the High-CRP categories, statin users showed a significantly lower event rates than non-users (P=0.02 and P=0.008, respectively, Figures). Additionally, multivariate Cox regression analysis in the High-CRP group revealed that statin use was independently associated with the primary endpoint (adjusted hazard ratio: 0.67 [95% confidence interval: 0.45–0.99]), even after the adjustment of covariants.

Conclusion

Statins may exert a favorable prognostic effect in PAD patients with highly elevated CRP, but not in those with low to moderate CRP level.

Event free survival

Funding Acknowledgement

Type of funding source: None

Late Adverse Cardiorenal Events of Catheter Procedure-Related Acute Kidney Injury After Transcatheter Aortic Valve Implantation

Data regarding the longitudinal effect of catheter procedure-related acute kidney injury (AKI) on clinical outcomes are limited. This study aimed to assess the late adverse cardiorenal events of AKI following transcatheter aortic valve implantation (TAVI). A total of 2,518 patients who underwent TAVI, excluding in-hospital deaths, were enrolled from the Japanese multicenter registry. The definition of AKI was determined using the Valve Academic Research Consortium-2 criteria. The incidence, predictors, major adverse renal and cardiac events (MARCE), and all-cause mortality of AKI were evaluated. MARCE included readmission for renal and heart failure (HF), hemodialysis requirement, and cardiovascular-renal death during the follow-up period. The incidence of AKI was 9.7% in the entire cohort. The significant predictive factors of AKI were men, diabetes mellitus, hypertension, chronic kidney disease, low albumin, overdose of contrast media, nontransfemoral approach, transfusion, vascular complications, and new pacemaker implantation. The rates of HF readmission and future hemodialysis were significantly higher in patients with AKI than in those without AKI (19.7% vs 9.0%, p <0.001, 3.3% vs 0.4%, p <0.001, respectively). Cox regression multivariate analysis showed that AKI occurrence was an independent predictive factor for the incremental risk of both MARCE and late mortality up to 4 years (hazard ratio [HR] 1.59, 95% confidence interval [CI] 0.75 to 1.20, p <0.001, HR 2.18, 95% CI 1.70 to 2.79; p <0.001, respectively). In conclusion, AKI occurrence was significantly associated with late adverse cardiorenal events after TAVI. Adequate clinical management can be expected to reduce AKI-related late phase cardiorenal damage even after successful TAVI.

Predictors and Prognostic Impact of Nutritional Changes After Transcatheter Aortic Valve Replacement

BACKGROUND

Little is known about changes in nutritional status as an index of frailty on clinical outcomes after transcatheter aortic valve replacement (TAVR). This study aimed to assess the clinical impact of serum albumin changes after TAVR.

METHODS

Changes in serum albumin levels from baseline to 1 year after TAVR were evaluated in 1524 patients who were classified as having hypoalbuminemia (<3.5 g/dl) and normoalbuminemia (≥3.5 g/dl) at each timepoint. The patients were categorized into 4 groups: NN (baseline normoalbuminemia, 1-year normoalbuminemia: n = 1119), HN (baseline hypoalbuminemia, 1-year normoalbuminemia: n = 202), NH (baseline normoalbuminemia, 1-year hypoalbuminemia: n = 121), and HH (baseline hypoalbuminemia, 1-year hypoalbuminemia: n = 82). We also defined late hypoalbuminemia as hypoalbuminemia identified at the 1-year assessment. Clinical outcomes were compared among 4 groups. Multivariable analysis was driven to assess the variables associated with late hypoalbuminemia and long-term mortality.

RESULTS

The cumulative 3-year mortality was significantly different among the 4 groups (NN: 11.4%, HN: 10.7%, NH: 25.4%, HH: 44.4%, p < 0.001). Multivariable Cox regression analysis revealed that the NH group had a higher mortality risk (hazard ratio [HR]; 2.80 and 3.53, 95% confidence interval [CI]; 1.71-4.57 and 2.06-6.06, p < 0.001 and p < 0.001, respectively), whereas the HN group had a similar risk (HR; 1.16, 95% CI; 0.66-2.06, p = 0.61) compared with the NN group. Baseline hypoalbuminemia, low body mass index, liver disease, peripheral artery disease, and hospital readmission within 1 year were predictors of late hypoalbuminemia (all p < 0.05).

CONCLUSION

Serial albumin assessment may identify poor prognostic subsets in patients with persistent and late acquired malnutrition after TAVR.

Clinical risk model for predicting 1-year mortality after transcatheter aortic valve replacement

Objectives

Estimating 1‐year life expectancy is an essential factor when evaluating appropriate indicators for transcatheter aortic valve replacement (TAVR).

Background

It is clinically useful in developing a reliable risk model for predicting 1‐year mortality after TAVR.

Methods

We evaluated 2,588 patients who underwent TAVR using data from the Optimized CathEter vAlvular iNtervention (OCEAN) Japanese multicenter registry from October 2013 to May 2017. The 1‐year clinical follow‐up was achieved by 99.5% of the entire population (n = 2,575). Patients were randomly divided into two cohorts: the derivation cohort (n = 1,931, 75% of the study population) and the validation cohort (n = 644). Considerable clinical variables including individual patient's comorbidities and frailty markers were used for predicting 1‐year mortality following TAVR.

Results

In the derivation cohort, a multivariate logistic regression analysis demonstrated that sex, body mass index, Clinical Frailty Scale, atrial fibrillation, peripheral artery disease, prior cardiac surgery, serum albumin, renal function as estimated glomerular filtration rate, and presence of pulmonary disease were independent predictors of 1‐year mortality after TAVR. Using these variables, a risk prediction model was constructed to estimate the 1‐year risk of mortality after TAVR. In the validation cohort, the risk prediction model revealed high discrimination ability and acceptable calibration with area under the curve of 0.763 (95% confidence interval, 0.728–0.795, p < .001) in the receiver operating characteristics curve analysis and a Hosmer–Lemeshow χ² statistic of 5.96 (p = .65).

Conclusions

This risk prediction model for 1‐year mortality may be a reliable tool for risk stratification and identification of adequate candidates in patients undergoing TAVR.

Hypo-attenuated leaflet thickening in surgically-implanted mitral bioprosthesis

Background

Hypo-attenuated leaflet thickening (HALT) in bioprosthetic aortic valve has been studied, but its equivalent in bioprosthetic mitral valve (bMV) remains uncharacterized. We sought to identify the prevalence, hemodynamic characteristics, and significance of anticoagulation therapy in bMV HALT.

Methods

A single-center cross-sectional study of 53 consecutive patients who underwent mitral valve replacement (MVR) with bMV between 2007 and 2017 was conducted. Cardiac-gated contrasted CT scans were obtained. Anticoagulant and antiplatelet therapy use were ascertained at the time of hospital discharge and CT scanning. Patient characteristics, postoperative stroke, and hemodynamic profile by echocardiogram were obtained to descriptively characterize the prevalence and characteristics associated with bMV HALT.

Results

Three patients (5.7%) were found to have a HALT on bMV. The mean time from index MVR to CT scan was 3.4 ± 0.8 years in HALT cohort and 3.4 ± 2.7 years in non-HALT cohort. Fifty patients (94.3%) were discharged on warfarin, and 37 patients (69.8%) were on warfarin at the time of CT scans. One patient with HALT was on therapeutic warfarin at the time of the CT scan that identified HALT. All three patients were asymptomatic at the time of CT scan. In patients with HALT, mean transmitral pressure gradient were 8, 5, and 2.7 mmHg, all with trivial or mild mitral regurgitation.

Conclusions

In this study, the prevalence of HALT was low at 5.7%, all presenting without symptoms. One patient presented with HALT while on therapeutic oral anticoagulation, which may suggest thrombotic etiology may not adequately explain HALT.

Silent Valsalva thrombus between the native Valsalva and balloon-expandable transcatheter heart valve: multicentre Japanese registry analysis

AIMS

The newly formed geometry between the native Valsalva and implanted transcatheter heart valve (THV) may induce local thrombogenicity. This study aimed to assess the incidence of and the clinical outcomes associated with Valsalva thrombus formation after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

We retrospectively evaluated the multidetector computed tomography (MDCT) data of 338 patients following transcatheter aortic valve implantation (TAVI) using a balloon-expandable THV. The Valsalva and leaflet thrombi were assessed by MDCT at the left coronary cusp (LCC), right coronary cusp (RCC), and non-coronary cusp (NCC). Combined endpoints such as death, stroke, and readmission for heart failure rates in patients with and without Valsalva and/or leaflet thrombus were examined at two years. The overall incidence of Valsalva and leaflet thrombi was 8.9% and 8.3%, respectively. Significant differences in the location of the Valsalva thrombus in the LCC, RCC, and NCC were noted (5.0%, 4.2%, 8.9%, respectively, p<0.001). The independent predictor for increased risk of Valsalva thrombus was high Valsalva area to implanted THV size ratio (odds ratio 11.8, 95% confidence interval [CI]: 1.67-83.0, p=0.013). Combined endpoints were similar in patients with and without Valsalva thrombus, Valsalva/leaflet thrombus, and leaflet thrombus (p>0.05 for all).

CONCLUSIONS

Valsalva thrombus was detected in 8.9% of patients following balloon-expandable THV implantation and was common in the LCC, but it did not increase the risk of adverse events after TAVI.

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Background

Although transcatheter aortic valve replacement (TAVR) is the least invasive treatment for patients with symptomatic aortic stenosis, some patients hesitate to undergo the procedure. We investigated the clinical impact of treatment delay after patient refusal of TAVR.

Methods and Results

We used the Japanese OCEAN (Optimized Catheter valvular intervention) regsitry data of 1542 patients who underwent TAVR. Refusal was defined as at least 1 refusal of TAVR at the time of informed consent. Patients were separated into 2 groups: refusal (28/1542, 1.8%) and non‐refusal (1514/1542, 98.2%). We compared the baseline characteristics, procedural outcomes, and mortality rates between the groups. Additionally, data on reasons for refusal and those leading to eventually undergoing TAVR were collected. Age, surgical risk scores, and frailty were higher in the refusal group than in the non‐refusal group (P<0.05 for all). Periprocedural complications did not differ between groups, whereas 30‐day and cumulative 1‐year mortality were significantly higher in the refusal group than in the non‐refusal group (7.1% versus 1.3%, P=0.008 and 28.8% versus 10.3%, P=0.010, respectively). Multivariate Cox regression analysis revealed that TAVR refusal was an independent predictor of increased midterm mortality (hazard ratio: 3.37; 95% confidence interval: 1.52–7.48; P=0.003). The most common reason for refusal was fear (13/28, 46.4%), and the most common reason for changing their mind was worsening heart failure (21/28, 75.0%). All patients in the refusal group decided to undergo TAVR within 20 months (median: 5.5 months).

Conclusions

Refusing TAVR even once led to poorer prognosis; therefore, this fact should be clearly discussed when obtaining informed consent.

124Impact of intimal tracking for recanalization of CTO lesions on long-term clinical outcomes

Background

For recanalization of coronary chronic total occlusion (CTO) lesions, subintimal guidewire tracking in both antegrade and retrograde approaches are commonly used.

Purpose

This study aimed to assess the impact of subintimal tracking on long-term clinical outcomes after recanalization of CTO lesions.

Methods

Between January 2009 and December 2016, 474 CTO lesions (434patients) were successfully recanalized in our center. After guidewire crossing in a CTO lesion, those lesions were divided into intimal tracking group (84.6%, n=401) and subintimal tracking group (15.4%, n=73) according to intravascular ultrasound (IVUS) findings. Long-term clinical outcomes including death, target lesion revascularization (TLR), target vessel revascularization (TVR) were compared between the two groups. In addition, the rate of re-occlusion after successful revascularization was also evaluated.

Results

The median follow-up period was 4.7 years (interquartile range, 2.8–6.1). There was no significant difference of the rate of cardiac death between the two groups (intimal tracking vs. subintimal tracking: 7.0% vs. 4.1%; hazard ratio, 0.61; 95% confidence interval [CI], 0.19 to 2.00; p=0.41), TLR (14.3% vs. 16.2%; hazard ratio, 1.34; 95% CI, 0.71 to 2.53; p=0.37), and TVR (17.5% vs. 20.3%; hazard ratio, 1.27; 95% CI, 0.72 to 2.23; p=0.42). However, the rate of re-occlusion was significantly higher in the subintimal tracking group than intimal tracking group at 3-years re-occlusion (4.2% vs. 14.5%; log-rank test, p=0.002, Figure). In the multivariate COX regression, subintimal guidewire tracking was an independent predictor of re-occlusion after CTO recanalization (HR: 5.40; 95% CI: 2.11–13.80; p<0.001).

Figure 1

Conclusions

Subintimal guidewire tracking for recanalization of coronary CTO was associated with significantly higher incidence of target lesion re-occlusion during long-term follow-up period.

Importance of Geriatric Nutritional Risk Index assessment in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Nutritional condition is one marker of patients' frailty. The Geriatric Nutritional Risk Index (GNRI) is a well-known marker of nutritional status. This study sought to assess the clinical outcomes of GNRI after transcatheter aortic valve replacement (TAVR).

METHODS

We evaluated the GNRI value of 1,613 patients who underwent TAVR using data from a Japanese multicenter registry. According to baseline GNRI, patients were classified into 3 groups: GNRI ≥92 (n = 1,085; 67.3%), GNRI 82-92 (n = 396; 24.6%), and GNRI ≤82 (n = 132; 8.2%). Baseline characteristics, procedural outcomes, and cumulative mortality rates were compared. In addition, GNRI correlations with other frailty components (gait speed, grip strength, and Clinical Frailty Scale) and Society of Thoracic Surgeons (STS) score were also evaluated.

RESULTS

Significantly increased mortality rates were observed across the 3 groups at 30 days (0.9%, 2.3%, and 6.8%, respectively; P < .001) and 1 year (6.5%, 16.4%, and 36.4%, respectively; P < .001). Both GNRI 82-92 and GNRI ≤82 (as a reference for GNRI ≥92) were independently associated with increased midterm mortality in the Cox regression multivariate model (hazard ratio: 1.97, 3.60; 95% confidence interval: 1.37-2.84, 2.30-5.64; P < .001, P < .001, respectively). The GNRI value was significantly correlated with gait speed (Spearman ρ = -0.15, P < .001), grip strength (ρ = 0.25, P < .001), Clinical Frailty Scale (ρ = -0.24, P < .001), and STS score (ρ = -0.29, P < .001).

CONCLUSIONS

GNRI is related to both frailty components and the STS score and is an important surrogate marker for predicting worse clinical outcomes after TAVR. Assessment of the GNRI may be considered when deciding on TAVR.

Prediction of major complications after hepatectomy using liver stiffness values determined by magnetic resonance elastography

BACKGROUND

Liver fibrosis is a risk factor for hepatectomy but cannot be determined accurately before hepatectomy because diagnostic procedures are too invasive. Magnetic resonance elastography (MRE) can determine liver stiffness (LS), a surrogate marker for assessing liver fibrosis, non-invasively. The aim of this study was to investigate whether the LS value determined by MRE is predictive of major complications after hepatectomy.

METHODS

This prospective study enrolled consecutive patients who underwent hepatic resection between April 2013 and August 2016. LS values were measured by imaging shear waves by MRE in the liver before hepatectomy. The primary endpoint was major complications, defined as Clavien-Dindo grade IIIa or above. Logistic regression analysis identified independent predictive factors, from which a logistic model to estimate the probability of major complications was constructed.

RESULTS

A total of 96 patients were included in the study. Major complications were observed in 15 patients (16 per cent). Multivariable logistic analysis confirmed that higher LS value (P = 0·021) and serum albumin level (P = 0·009) were independent predictive factors for major complications after hepatectomy. Receiver operating characteristic (ROC) analysis showed that the best LS cut-off value was 4·3 kPa for detecting major complications, comparable to liver fibrosis grade F4, with a sensitivity of 80 per cent and specificity of 82 per cent. A logistic model using the LS value and serum albumin level to estimate the probability of major complications was constructed; the area under the ROC curve for predicting major complications was 0·84.

CONCLUSION

The LS value determined by MRE in patients undergoing hepatectomy was an independent predictive factor for major complications.

Impact of pre-procedural hyponatremia on clinical outcomes after transcatheter aortic valve replacement: A propensity-matched analysis

BACKGROUND

Hyponatremia is associated with the increased risk of early and late mortality in patients with cardiac disease. This study aimed to assess the prognostic value of hyponatremia in patients who had undergone transcatheter aortic valve replacement (TAVR).

METHODS

We investigated 1,215 consecutive patients (mean age: 84.4 ± 5.0 years) who underwent TAVR using data from the Optimized CathEter vAlvular iNtervention (OCEAN)-TAVR Japanese multicenter registry. Hyponatremia was defined as a serum sodium value less than 135 mEq/L. The baseline characteristics, procedural outcomes, all-cause, cardiovascular, and non-cardiovascular mortality were compared between patients with hyponatremia (n = 106, 8.7%) and without hyponatremia (n = 1,109, 91.3%). A propensity-matching analysis was used to adjust for the non-uniform patient characteristics.

RESULTS

Differences in the baseline characteristics were observed between the two groups regarding the prevalence of pulmonary disease (37.7% vs. 28.9%, P = 0.04) and the performance of non-elective TAVR (10.4% vs. 4.2%, P = 0.01), although these were minimized in the matched model. The 30-day mortality rates differed between the two groups (7.6% vs. 1.4%, P < 0.001). During a mean follow-up of 330 days, the all-cause and cardiovascular mid-term mortality were higher in the hyponatremia group than in the non-hyponatremia group (log-rank test: P = 0.0047, and P < 0.001, respectively). The three findings above were not attenuated in the propensity-matched model (P < 0.001, P = 0.0044, and P = 0.014, respectively). In contrast, there was no difference in non-cardiovascular mortality between the two groups in both the overall and matched model (P = 0.40 and P = 0.13, respectively).

CONCLUSIONS

Pre-procedural hyponatremia may be a useful marker for predicting early and mid-term clinical outcomes after TAVR.

The incidence, predictive factors and prognosis of acute pulmonary complications after transcatheter aortic valve implantation

OBJECTIVES

Although acute pulmonary complications (APCs), such as the exacerbation of pulmonary disease (PD) or a newly developed pulmonary event, are thought to be catastrophic after invasive therapy, little is known about the occurrence of APCs after transcatheter aortic valve implantation (TAVI). This study aims to clarify the incidence, predictive factors and impact of APCs on prognosis after TAVI.

METHODS

We identified 749 patients who underwent TAVI, using data from the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) Japanese multicentre registry. APCs were defined as exacerbation of a comorbidity or newly developed PD during hospitalization. Patients were divided into 2 groups: an APC group (1.5%, 11/749) and a non-APC group (98.5%, 738/749). Clinical and prognostic outcomes were compared, and predictive factors for APCs were assessed.

RESULTS

Procedure-related death did not differ between the groups (0.4% vs 0.0%, P = 1.00), although 30-day mortality was significantly higher in the APC group than in the non-APC group (27.3% vs 1.6%, P = 0.001) and the difference in cumulative 1-year mortality increased further (72.7% vs 8.6%, log-rank test: P < 0.001). In particular, concomitant PD and transapical (TA) approach were identified as predictors of APCs after TAVI [univariable odds ratio (uOR) = 24.2, 95% confidence interval (CI) = 3.08-189.9, P = 0.002; uOR = 3.69, 95% CI = 1.11-12.3, P = 0.033, respectively].

CONCLUSIONS

Although rare, the occurrence of APCs after TAVI was associated with extremely poor prognosis. Patients undergoing TAVI with concomitant PD and/or TA require careful consideration to avoid the risk of APCs.

Novel proctorship effectively teaches interventionists coronary artery chronic total occlusion lesions

BACKGROUND

Interventionists' experience and skills are essential factors for successful chronic total occlusion-percutaneous coronary intervention (CTO-PCI). However, the construction of theoretical strategy independent from interventionists' procedure may also improve it. We sought to assess the feasibility of CTO-PCI using an educational system supported by a single expert proctor.

METHODS

A total of 160 patients underwent CTO-PCI between 2009 and 2016 at 92 Japanese centers in the Hands-on proctorship project. The CTO-PCI strategy was discussed with all participants and their specialists, before and during the procedure. We divided patients into 2 groups based on the CTO-PCI experience of their interventionist: (1) the less experienced group (CTO-PCI ≤50 cases, n=65) and (2) the more experienced group (CTO-PCI >50 cases, n=95). Baseline characteristics, procedural complications, and clinical outcomes were compared between groups.

RESULTS

No significant differences in patient age, sex, prevalence for coronary risk factors, and lesion complexity was observed between groups. The retrograde approach was used equivalently between groups (55.4% vs. 60.0%, p=0.56), and procedural success rates were similar (96.9% vs. 90.5%, p=0.12). The rate of proctor's bailout for recanalization were not frequent between groups (4.6% vs. 5.3%, p=0.85). No procedure-related mortality was noted in either group. In addition, no significant differences in procedural cardiac complications, including coronary dissection, perforation, or tamponade, were observed between groups (10.8% vs. 14.7%, p=0.47).

CONCLUSIONS

The expert-supported CTO-PCI maintained high success rates regardless of interventionists' experience. This highlights the importance of theoretical strategy for the management patients undergoing CTO-PCI.

Impact of frailty markers on outcomes after transcatheter aortic valve replacement: insights from a Japanese multicenter registry

There are no standardized criteria for measuring patients' frailty. We examined prognosis based on four frailty markers [serum albumin level, grip strength, gait speed, and clinical frailty scale (CFS)] in patients who underwent transcatheter aortic valve replacement (TAVR) between October 2013 and April 2016 and were recorded in the Optimized CathEter vAlvular iNtervention (OCEAN) Japanese multicenter registry. Serum albumin level was assessed by dividing patients into two groups: hypoalbuminemia or non-hypoalbuminemia according to their serum albumin level. Clinical outcomes including all-cause, cardiovascular and non-cardiovascular mortality rates after TAVR were compared. During the follow-up period cumulative all-cause, cardiovascular and non-cardiovascular mortality rates were significantly higher in the hypoalbuminemia group than in the non-hypoalbuminemia group. This result remained unchanged even after a propensity-matched model was used in terms of cumulative all-cause and non-cardiovascular mortality; however, differences in cardiovascular mortality rates were attenuated. To consider the impact of grip strength patients were divided into a low or high peak grip strength group based on classification and regression tree (CART) survival analysis. The clinical outcomes for each sex were compared between the two groups. In both sexes the cumulative 1-year mortality rates were significantly different between the two groups. To investigate gait speed patients were classified into two gait speed groups (low or high gait speed group) based on CART survival analysis. Clinical outcomes were compared between the two groups. The cumulative 1-year mortality rate was significantly different between the two gait speed groups. The effect of CFS on prognosis after TAVR was assessed. Patients were categorized into five groups based on the following CFS scores: CFS1-3, CFS4, CFS5, CFS6, and CFS ≥7. We evaluated the relationship between the CFS score and other indicators of frailty markers. We also assessed the mid-term mortality among the five groups. The CFS score had a significant correlation with other frailty markers. The cumulative 1-year mortality increased with an increasing CFS score. In the Cox regression multivariable analysis, the CFS score was an independent predictive factor of an increased late cumulative mortality risk. In conclusion, the results suggest that serum albumin level, grip strength, gait speed, and CFS score are all useful indicators when considering the optimal indications and risk stratification for TAVR.

Impact of the Clinical Frailty Scale on Outcomes After Transcatheter Aortic Valve Replacement

Background:

The semiquantitative Clinical Frailty Scale (CFS) is a simple tool to assess patients’ frailty and has been shown to correlate with mortality in elderly patients even when evaluated by nongeriatricians. The aim of the current study was to determine the prognostic value of CFS in patients who underwent transcatheter aortic valve replacement.

Methods:

We utilized the OCEAN (Optimized Catheter Valvular Intervention) Japanese multicenter registry to review data of 1215 patients who underwent transcatheter aortic valve replacement. Patients were categorized into 5 groups based on the CFS stages: CFS 1-3, CFS 4, CFS 5, CFS 6, and CFS ≥7. We subsequently evaluated the relationship between CFS grading and other indicators of frailty, including body mass index, serum albumin, gait speed, and mean hand grip. We also assessed differences in baseline characteristics, procedural outcomes, and early and midterm mortality among the 5 groups.

Results:

Patient distribution into the 5 CFS groups was as follows: 38.0% (CFS 1-3), 32.9% (CFS4), 15.1% (CFS 5), 10.0% (CFS 6), and 4.0% (CFS ≥7). The CFS grade showed significant correlation with body mass index (Spearman’s ρ=−0.077, P =0.007), albumin (ρ=−0.22, P <0.001), gait speed (ρ=−0.28, P <0.001), and grip strength (ρ=−0.26, P <0.001). Cumulative 1-year mortality increased with increasing CFS stage (7.2%, 8.6%. 15.7%, 16.9%, 44.1%, P <0.001). In a Cox regression multivariate analysis, the CFS (per 1 category increase) was an independent predictive factor of increased late cumulative mortality risk (hazard ratio, 1.28; 95% confidence interval, 1.10–1.49; P <0.001).

Conclusions:

In addition to reflecting the degree of frailty, the CFS was a useful marker for predicting late mortality in an elderly transcatheter aortic valve replacement cohort.

Microvascular resistance in response to iodinated contrast media in normal and functionally impaired kidneys

Contrast‐induced nephropathy (CIN) is considered to result from intrarenal vasoconstriction, and occurs more frequently in impaired than in normal kidneys. It was hypothesized that iodinated contrast media would markedly change renal blood flow and vascular resistance in functionally impaired kidneys. Thirty‐six patients were enrolled (32 men; mean age, 75.3 ± 7.6 years) undergoing diagnostic coronary angiography and were divided into two groups based on the presence of chronic kidney disease (CKD), defined as an estimated glomerular filtration rate (eGFR) of < 60 mL/min per 1.73 m² (CKD and non‐CKD groups, n = 18 in both). Average peak velocity (APV) and renal artery resistance index (RI) were measured by Doppler flow wire before and after administration of the iodinated contrast media. The APV and the RI were positively and inversely correlated with the eGFR at baseline, respectively (APV, R = 0.545, P = 0.001; RI, R = −0.627, P < 0.001). Mean RI was significantly higher (P = 0.015) and APV was significantly lower (P = 0.026) in the CKD than in the non‐CKD group. Both APV (P < 0.001) and RI (P = 0.002) were significantly changed following contrast media administration in the non‐CKD group, but not in the CKD group (APV, P = 0.258; RI, P = 0.707). Although renal arterial resistance was higher in patients with CKD, it was not affected by contrast media administration, suggesting that patients with CKD could have an attenuated response to contrast media.