藤田 英雄

Acute myocardial infarction (AMI) is more frequently observed in patients with chronic kidney disease (CKD) than in patients without CKD. Initial treatment strategy for AMI includes primary percutaneous coronary intervention (PCI), which requires substantial amount of contrast media. We hypothesized that the clinical outcomes are comparable or worse in patients with AMI and advanced CKD off chronic hemodialysis as compared to patients with AMI and advanced CKD on chronic hemodialysis. The purpose of this study was to compare the clinical outcomes of patients with AMI and advanced CKD on hemodialysis versus off hemodialysis. A total of 148 patients with estimated glomerular filtration rate &amp lt  30 ml/min/1.73 m2 on admission were included and were divided into the HD group (n = 68) and non-HD group (n = 80). The length of hospitalization was significantly less in the HD group (15.7 ± 14.8 days) than in the non-HD group (22.4 ± 21.3 days) (P = 0.01). In-hospital death was significantly less in the HD group (10.3%) than in the non-HD group (25.0%) (P = 0.02). While the non-HD group was not significantly associated with in-hospital death after controlling clinical covariates, the non-HD group (odd ratio 2.89, 95% confidence interval 1.03–8.12, P = 0.04) was significantly associated with long hospitalization even after controlling clinical covariates. In conclusion, as compared to advanced CKD on chronic hemodialysis, advanced CKD off hemodialysis had higher morbidity and mortality in patients with AMI. Advanced CKD off hemodialysis was closely associated with long hospitalization even after controlling clinical factors.

Previous studies suggested that right ventricular pacing was associated with pacing-induced cardiac dysfunction (PICD). The purpose of this study was to investigate the clinical characteristics including the incidence of undiagnosed cardiac sarcoidosis (CS) in patients with atrioventricular block (AVB) who manifest PICD. We retrospectively investigated consecutive patients with permanent pacemaker (PPM) undergoing a first-generator replacement surgery with a new PPM or an upgrade procedure to a cardiac resynchronization therapy (CRT) device between December 1, 2011 and June 30, 2017. Patients with AVB showing normal echocardiographic findings before PPM implantation were included and divided into 2 groups: patients with post-PPM left ventricular ejection fraction (LVEF) &lt 40% and/or undergoing an upgrade procedure to CRT (PICD group) and patients with post-PPM LVEF ≥ 40% who underwent replacement surgery with a new PPM (no-PICD group). There were 15 and 41 patients in the PICD and no-PICD groups, respectively. A wider-paced QRS duration just after the PPM implantation and/or lower pre-PPM LVEF was observed in the PICD group. Furthermore, 46.7% of the PICD patients (7/15) satisfied the diagnostic criteria for CS according to the guideline of the Japanese Circulation Society, although no patients fulfilled these criteria before PPM implantation. In conclusion, a high incidence of CS was observed in patients with AVB who had PICD. However, none of these patients was diagnosed with CS before PPM implantation.

© 2018 by the American Diabetes Association. OBJECTIVE Diabetes is associated with high risk of cardiovascular (CV) events, particularly in patients with dyslipidemia and diabetic complications. We investigated the incidence of CV events with intensive or standard lipid-lowering therapy in patients with hypercholesterolemia, diabetic retinopathy, and no history of coronary artery disease (treat-to-target approach). RESEARCH DESIGN AND METHODS In this multicenter, prospective, randomized, open-label, blinded end point study, eligible patients were randomly assigned (1:1) to intensive statin therapy targeting LDL cholesterol (LDL-C) <70 mg/dL (n = 2,518) or standard statin therapy targeting LDL-C 100-120 mg/dL (n = 2,524). RESULTS Mean follow-up was 37± 13months. LDL-C at 36 months was 76.5± 21.6mg/dL in the intensive group and 104.1 ± 22.1 mg/dL in the standard group (P < 0.001). The primary end point events occurred in 129 intensive group patients and 153 standard group patients (hazard ratio [HR] 0.84 [95% CI 0.67-1.07]; P = 0.15). The relationship between the LDL-C difference in the two groups and the event reduction rate was consistent with primary prevention studies in patients with diabetes. Exploratory findings showed significantly fewer cerebral events in the intensive group (HR 0.52 [95% CI 0.31-0.88]; P = 0.01). Safety did not differ significantly between the two groups. CONCLUSIONS We found no significant decrease in CV events or CV-associated deaths with intensive therapy, possibly because our between-group difference of LDL-C was lower than expected (27.7 mg/dL at 36 months of treatment). The potential benefit of achieving LDL-C <70 mg/dL in a treat-to-target strategy in high-risk patients deserves further investigation.

OBJECTIVEDiabetes is associated with high risk of cardiovascular (CV) events, particularly in patients with dyslipidemia and diabetic complications. We investigated the incidence of CV events with intensive or standard lipid-lowering therapy in patients with hypercholesterolemia, diabetic retinopathy, and no history of coronary artery disease (treat-to-target approach).RESEARCH DESIGN AND METHODSIn this multicenter, prospective, randomized, open-label, blinded end point study, eligible patients were randomly assigned (1:1) to intensive statin therapy targeting LDL cholesterol (LDL-C) <70 mg/dL (n = 2,518) or standard statin therapy targeting LDL-C 100-120 mg/dL (n = 2,524).RESULTSMean follow-up was 376 +/- 13 months. LDL-C at 36 months was 76.56 +/- 21.6 mg/dL in the intensive group and 104.1 +/- 22.1 mg/dL in the standard group (P < 0.001). The primary end point events occurred in 129 intensive group patients and 153 standard group patients (hazard ratio [HR] 0.84 [95% CI 0.67-1.07]; P = 0.15). The relationship between the LDL-C difference in the two groups and the event reduction rate was consistent with primary prevention studies in patients with diabetes. Exploratory findings showed significantly fewer cerebral events in the intensive group (HR 0.52 [95% CI 0.31-0.88]; P = 0.01). Safety did not differ significantly between the two groups.CONCLUSIONSWe found no significant decrease in CV events or CV-associated deaths with intensive therapy, possibly because our between-group difference of LDL-C was lower than expected (27.7 mg/dL at 36 months of treatment). The potential benefit of achieving LDL-C < 70 mg/dL in a treat-to-target strategy in high-risk patients deserves further investigation.

Bleeding complications following percutaneous coronary interventions (PCI) have been closely associated with morbidity and mortality. Although radial arteries have been widely used in current PCI, including primary PCI, transfemoral PCI remains necessary for complex PCI. The purpose of this study was to compare the incidence of complications following elective transfemoral PCI between manual compression with and without protamine. We identified 249 consecutive patients who underwent elective transfemoral PCI from hospital records, and divided them into two groups: patients who used protamine for manual compression (the protamine group n = 205) and patients who did not (the non-protamine group, n = 44). Complications including acute thrombosis, bleeding requiring blood transfusion, transient hypotension, skin rash, and death within 30 days were compared between groups. The baseline clinical and procedural characteristics were comparable between the protamine and non-protamine groups. The incidences of all complications were not different between the protamine (5.9%) and the non-protamine groups (9.1%) (P = 0.43). While more than 90% of the patients received drug-eluting stent implantation, there was no acute thrombus in either group. The incidence of bleeding requiring blood transfusion was significantly lower in the protamine group (0.5%) than in the non-protamine group (6.8%) (P = 0.002). Multivariate logistic regression analysis revealed the inverse association between protamine use and bleeding requiring blood transfusion (odds ratio 0.08, 95% confidence interval 0.01-0.84, P = 0.04). In conclusion, the use of protamine for manual compression following elective transfemoral PCI was safe and was associated with less bleeding complications.

Primary percutaneous coronary interventions (PCI) have been developed to improve clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). In primary PCI, the door-to-balloon time (DTBT) is closely associated with mortality and morbidity. The purpose of this study was to find determinants of short and long DTBT. From our hospital record, we included 214 STEMI patients, and divided into the short DTBT group (DTBT &lt  60 min, n = 60), the intermediate DTBT group (60 min ≤ DTBT ≤ 120 min, n = 121) and the long DTBT group (DTBT &gt  120 min, n = 33). In-hospital mortality was highest in the long DTBT group (24.2%), followed by the intermediate DTBT group (5.8%), and lowest in the short DTBT group (0%) (&lt  0.001). Transfers from local clinics or hospitals (OR 3.43, 95% CI 1.72–6.83, P &lt  0.001) were significantly associated with short DTBT, whereas Killip class 3 or 4 (vs. Killip class 1 or 2: OR 0.20, 95% CI 0.06–0.64, P = 0.007) was inversely associated with short DTBT in multivariate analysis. In conclusion, transfer from local clinics/hospitals was associated with short DTBT. Our results may suggest the current limitation of ambulance system, which does not include pre-hospital ECG system, in Japan. The development of pre-hospital ECG system would be needed for better management in STEMI.

Slow flow is a serious complication in primary percutaneous coronary intervention (PCI) and is associated with poor clinical outcomes. Intravascular ultrasound (IVUS)-guided PCI may improve clinical outcomes after drug-eluting stent implantation. The purpose of this study was to seek the factors of slow flow following stent implantation, including factors related to IVUS-guided primary PCI. The study population consisted of 339 ST-elevation myocardial infarction patients, who underwent stent deployment with IVUS. During PCI, 56 patients (16.5%) had transient or permanent slow flow. Multivariate logistic regression analysis showed age (OR 1.04, 95% CI 1.01–1.07, P = 0.01), low attenuation plaque on IVUS (OR 3.38, 95% CI 1.70–6.72, P = 0.001), initial Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 (vs. TIMI 0: OR 0.44, 95% CI 0.20–0.99, P = 0.046), and the ratio of stent diameter to vessel diameter (per 0.1 increase: OR 2.63, 95% CI 1.84–3.77, P &lt  0.001) were significantly associated with slow flow. A ratio of stent diameter to vessel diameter of 0.71 had an 80.4% sensitivity and 56.9% specificity to predict slow flow. There was no significant difference in ischemic-driven target vessel revascularization between the modest stent expansion (ratio of stent diameter to vessel diameter &lt 0.71) and aggressive stent expansion (ratio of stent diameter to vessel diameter ≥0.71) strategies. Unlike other variables, the ratio of stent diameter to vessel diameter was the only modifiable factor. The modest stent expansion strategy should be considered to prevent slow flow following stent implantation in IVUS-guided primary PCI.

Background: The guide extension catheter is frequently used in current percutaneous coronary intervention, and the GuideLiner (Vascular Solutions Inc., Minneapolis, MN) has been the standard guide extension catheter. Recently, the Guideplus (Nipro, Osaka, Japan) has emerged as a new guide extension catheter. The aim of the present study was to compare device performance between the Guideplus and GuideLiner. Methods: We compared the purpose of guide extension catheter and the device unsuccessful rate between the Guideplus and GuideLiner. We classified the purpose of guide extension catheter into 4 categories: (1) to advance devices into the target lesion, (2) to engage guide catheter into the ostium, (3) to support the small profile balloon crossing the CTO or 99% stenosis that the microcatheter could not cross, and (4) others. Results: Ninety-two lesions were classified as the Guideplus group, whereas 103 lesions were classified as the GuideLiner group. The purpose of guide extension catheter was significantly different between the 2 groups (P &lt 0.001). The Guideplus was frequently used to support the small profile balloon crossing the CTO or 99% stenosis (20.7%), whereas the GuideLiner was not used (0%). The device unsuccessful rate was significantly less in the Guideplus (8.7%) than in the GuideLiner (20.4%) (P = 0.022). Conclusions: The purpose of guide extension catheter was significantly different between the Guideplus and GuideLiner. The Guideplus was more frequently used to support the small profile balloon crossing the CTO or 99% stenosis. The device unsuccessful rate was less in the Guideplus, which may suggest the better performance as the guide extension catheter.

Severe dissection and hematoma following stent implantation can cause acute vessel closure, which requires an immediate bailout procedure. However, bailout from such a situation may not be easy, especially when the hematoma extends to the distal segment of a coronary artery. We present a case of 73-year-old woman with effort angina who underwent PCI to the right coronary artery (RCA). Following stent implantation, there was a massive hematoma from the distal edge of the stent. We tried to create re-entry at the distal part of the hematoma, but were not successful. We managed her conservatively without additional stent placement or creating re-entry. Follow-up coronary angiography on day 68 showed excellent coronary flow. Intravascular ultrasound demonstrated complete healing of the hematoma. A hematoma caused by edge dissection is a challenging complication. Additional stent implantation to cover the entire length of the hematoma and/or cutting balloon dilatation to create re-entry are options however, these procedures may worsen the situation. Our case clearly showed healing of dissection and hematoma without creating re-entry or additional stent implantation. Conservative management should be considered an option for severe edge dissection and hematoma following stent implantation.

Blunt chest trauma can cause a wide variety of injuries including acute myocardial infarction (AMI). Although AMI due to coronary artery dissection caused by blunt chest trauma is very rare, it is associated with high morbidity and mortality. In the vast majority of patients with AMI, primary percutaneous coronary interventions (PCI) are performed to recanalize obstructed arteries, but PCI carries a substantial risk of hemorrhagic complications in the acute phase of trauma. We report a case of AMI due to right coronary artery (RCA) dissection caused by blunt chest trauma. The totally obstructed RCA was spontaneously recanalized with medical therapy. We could avoid primary PCI in the acute phase of blunt chest trauma because electrocardiogram showed early reperfusion signs. We performed an elective PCI in the subacute phase when the risk of bleeding subsided. Since the risk of severe hemorrhagic complications is greater in the acute phase of blunt chest trauma as compared with the late phase, deferring emergency PCI is reasonable if signs of recanalization are observed.

Because rotational atherectomy (RA) has several unique complications, such as burr entrapment, vessel perforation, and slow flow, it is important for interventional cardiologists to be familiar with bailout procedures for such complications. The principal part of bailout procedures is to keep a guidewire in the target coronary artery during the procedure. However, it is not easy to keep a guidewire in the same position during the removal of a burr because the length of the RA guidewires is 300 cm, and the removal of a burr requires collaboration between the primary operator and an assistant. We describe the case of an 83-year-old male with stable angina. We performed RA to the left anterior descending artery, and removed the burr using a KUSABI (Kaneka Medix Corporation, OSAKA, Japan) trapping balloon technique without activating the dynaglide mode. This simple technique would help RA operators remove a burr more reliably than the conventional removal technique.

Aerobic training based on anaerobic threshold (AT) is well-known to improve cardiac function, exercise capacity, and long-term outcomes of patients with heart failure. Recent reports suggested that high-intensity interval training (HIIT) for patients with cardiovascular disease may improve cardiopulmonary exercise capacity. We present a 61-year-old male patient of severe left ventricular dysfunction with left ventricular assisted device (LVAD). Following HIIT for 8 weeks, exercise capacity and muscle strength have improved without worsening left ventricular function. Our case showed the possibility that HIIT was feasible and effective even in patients with LVAD.

Percutaneous coronary interventions to ostial left anterior descending artery (LAD)-acute myocardial infarction (AMI) were challenging, especially in crossover stenting from left main trunk (LMT) to LAD. The clinical outcomes of ostial LAD-AMI that needed crossover stenting were not well investigated. The objective of this study was to compare the clinical outcomes of LMT crossover stenting with those of ostial LAD just proximal (jp) stenting. Between January 2009 and March 2016, 1499 patients were diagnosed as AMI in our institution. Among them, 76 ostial LAD-AMIs were included in this study, and divided into 30 LMT crossover stenting (the crossover group) and 46 jp stenting (the jp stenting group). The primary endpoint was major cardiovascular events (MACE) defined as the composite of cardiac death, acute myocardial infarction (AMI), stent thrombosis (ST), target lesion revascularization (TLR) and target vessel revascularization (TVR). The frequency of MACE was comparable between the 2 groups (16.7% in the crossover group and 21.7% in the jp stenting group, P = 0.587). Similarly, the frequency of cardiac death was comparable between the 2 groups (6.7% in the crossover group and 13.0% in the jp stenting group, P = 0.376). The frequencies of TLR (6.7% in the crossover group and 6.5% in the jp stenting group, P = 0.980) and TVR (10.0% in the crossover group and 8.7% in the jp stenting group, P = 0.848) were not significantly different between the 2 groups. In conclusion, the clinical outcomes of the crossover stenting were comparable to the jp stenting in the stenting strategy for ostial LAD-AMI. LMT-LAD crossover stenting would be the acceptable strategy for ostial LAD-AMI.

Overall mortality and neurologic outcome of patients treated by veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was still not satisfactory. The aim of this study was to clarify the determinants of survival and favorable neurologic outcomes in patients with ischemic heart disease (IHD) treated by V-A ECMO. We identified IHD patients who received V-A ECMO, and divided those patients into the survived and the in-hospital death group. Multivariate logistic regression analysis was performed to identify the determinants of survival and favorable neurologic outcomes. Fifty-eight patients were divided into the in-hospital death group (n = 35) and the survived group (n = 23). Cardiogenic arrest for the reason for V-A ECMO introduction (vs. non-cardiac arrest: OR 0.34, 95% CI 0.002–0.65, P = 0.03) and final thrombolysis in myocardial infarction (TIMI-3) flow grade (vs. TIMI ≤2 flow grade: OR 17.44, 95% CI 1.65–184.04, P = 0.02) were determinants of in-hospital survival. Time from collapse to initiation of V-A ECMO was inversely associated with favorable neurologic function (10 min increase OR 0.49, 95% CI 0.28–0.89, P = 0.02), while final TIMI-3 flow grade was not associated with favorable neurologic function. In conclusion, the rapid establishment of V-A ECMO system as well as obtaining TIMI-3 flow grade should be sought for better survival with maintaining neurological function in IHD patients who requires V-A ECMO.

A 74-year-old woman who developed atrial tachycardia following the Cox-Maze IV procedure underwent catheter ablation. The reentrant circuit included the coronary sinus (CS), Marshall bundle (MB), distal MB-left atrial (LA) connection, and anterolateral mitral annulus. The distal MB-LA connection was the last barrier in the conduction pathway between the CS and the left atrium.

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, and carries an increased risk of cardiogenic embolism. Oral anticoagulants (OACs) including warfarin and/or non-vitamin K antagonists can prevent the majority of these events. The Saitama AF Registry was a community-based survey of patients with AF in Saitama City, which represents an urban community in Japan. A total of 75 institutions participated in the registry and attempted to enroll consecutive patients with AF from September 2014 to August 2015. The aim of the present study was to examine the clinical characteristics of patients with AF using data of the Saitama AF Registry. In addition, we investigated the difference in clinical characteristics of the patients between small-sized hospitals and large-sized hospitals. A total of 3591 patients were enrolled; 57.7% of all patients were enrolled from small-sized hospitals, whereas 42.3% were from large-sized hospitals. The patients from small-sized hospitals had higher CHADS(2) score than those from large-sized hospitals. Approximately, 80% of all patients were treated with OACs, and the prescription rate was higher in patients with CHADS(2) score ae&lt;yen&gt; 2 from both small-sized hospitals and large-sized hospitals. In conclusion, the present study demonstrated an appropriate use of OACs for high-risk patients with CHADS(2) score ae&lt;yen&gt;2 in Saitama City regardless of hospital size.

While most of pulmonary thromboembolism (PE) cases can be managed by thrombolytic and anticoagulation therapy, massive PE remains a life-threatening disease. Although surgical embolectomy can be a curative therapy for massive PE, peri-operative mortality for hemodynamically collapsed PE is extremely high. We present a case of hemodynamically collapsed massive PE. We avoided either thrombolytic therapy or surgical embolectomy, because the patient had recent cerebral contusion. Therefore, we managed the patient with the combination of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and conventional anticoagulation, which dramatically improved the patient’s hemodynamics. In conclusion, the combination of V-A ECMO and conventional anticoagulation may be the preferred first line therapy for the patients with cardiogenic shock following massive PE.

A 79-year-old male who had a history of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) received coronary angiography (CAG), because of angina pectoris. CAG showed in-stent restenosis of the paclitaxel-eluting stent (PES). Since the devices could not pass the lesion, we performed rotational atherectomy. Although we could not identify the calcified lesion by the optical frequency domain imaging (OFDI) findings because of strong attenuation, the intravascular ultrasound (IVUS) image showed the superficial calcification. On the other hand, strong attenuation in OFDI suggested the presence of foamy macrophage, which was essential for the diagnosis of neoatherosclerosis. We could obtain a favorable result by deploying another drug-eluting stent. While an earlier report showed the calcified neoatherosclerosis following bare-metal stent implantation, we clearly showed the calcified neoatherosclerosis following PES implantation.

Postprandial hypertriglyceridemia and hyperglycemia may promote endothelial and hemorheological dysfunction. The present study investigated the effects of pravastatin on endothelial function and hemorheology in patients with stable angina pectoris (AP) before and after eating a test meal. We recruited 26 patients with stable AP who had impaired glucose tolerance and mild dyslipidemia and six healthy men as controls to assess endothelial function and hemorheological behavior. In each group, we measured forearm blood flow (FBF) during post-ischemic reactive hyperemia and obtained blood samples before and 2 h after the test meal. Pravastatin 20 mg/day was then commenced in the 26 AP patients. The above tests were repeated after 2 days and 6 months. Maximum FBF during hyperemia in the baseline fasting phase was significantly lower in the AP patients than in the controls (p &lt; 0.05). Fasting and postprandial FBF during reactive hyperemia time-dependently improved after pravastatin treatment (p &lt; 0.05 vs. baseline data for each phase). Pravastatin treatment for 6 months, but not for 2 days, inhibited leukocyte activation and improved hemorheological parameters. In conclusion, pravastatin treatment for 6 months improved fasting and postprandial endothelial and hemorheological dysfunction in AP patients.

It is of utmost importance to minimize the door-to-balloon time for the initial treatment of ST-elevation acute myocardial infarction. In this case report, we made all kinds of efforts to minimize procedures in the emergency department (ED minimization) as well as in the catheter laboratory without sacrificing safety.

Background: The optimal strategy for diffuse right coronary artery (RCA) stenosis remains unclear. Objective: The objective of this study was to compare the mid-term outcomes of "complete full-metal jacket (c-FMJ) stenting strategy" with "incomplete full-metal jacket (i-FMJ) stenting strategy" for the diffuse long RCA lesion using drug-eluting stents (DES). Methods: Between July 2007 and October 2015, 121 patients underwent percutaneous coronary intervention (PCI) for diffuse RCA lesions using DES. Fifty-three patients underwent c-FMJ PCI, whereas 68 patients underwent i-FMJ. Thirty patients received angiographical follow-up in the c-FMJ group, while 34 patients received angiographical follow-up in the i-FMJ group. The primary endpoint was major adverse cardiac events (MACE): cardiac death, stent thrombosis (ST), target lesion revascularization (TLR), and target vessel revascularization (TVR). Results: The incidence of MACE was significantly lower in the c-FMJ group (13.3%) as compared to the iFMJ group (41.2%) (p = 0.013). There was no cardiac death in either group. The incidence of ST was comparable between the i-FMJ group (2.9%) and c-FMJ group (3.3%) (p = 1.00), while TLR was significantly less in the c-FMJ group (6.7%) compared to the i-FMJ group (32.4%) (p = 0.011). Conclusions: The mid-term MACE was significantly less in the c-FMJ group than in the i-FMJ group, indicating that c-FMJ stenting was a favorable strategy for the diffuse long RCA lesion. (C) 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

While rotational atherectomy (RA) is used for complex lesions in percutaneous coronary intervention, there are several contraindications such as unprotected left main stenosis or left ventricular dysfunction. We previously reported that the incidence of in-hospital complications was significantly greater in off-label as compared to on-label use RA. However, the mid-term clinical outcomes between off-label and on-label RA have not been investigated. The purpose of this study was to compare the mid-term clinical outcomes between off-label (n = 156) and on-label RA (n = 94). The primary endpoint was the incidence of major adverse cardiovascular events (MACE) defined as the composite of ischemia-driven target vessel revascularization (TVR), non-fatal MI, and all-cause death. We also identified 154 patients who underwent RA and follow-up angiography within 1 year, and compared quantitative coronary analysis between the off-label group (n = 96) and on-label group (n = 58). There was no significant difference in late luminal loss between the groups (0.03 +/- 0.53 mm in the off-label and -0.05 +/- 0.44 mm in the on-label groups, P = 0.57). However, the incidence of MACE was less in the on-label group (3.2 %) as compared to the off-label group (9.0 %) without reaching statistical significance (P = 0.08). In conclusion, mid-term clinical outcomes tended to be worse in the off-label group than in the on-label group. We may have to follow-up the patient who underwent off-label RA more carefully than the patient who underwent on-label RA.

BACKGROUND: Diet and fluid restrictions that need continuous self-management are among the most difficult aspects of dialysis treatment. Smartphone applications may be useful for supporting self-management. OBJECTIVE: Our objective is to investigate the feasibility and usability of a novel smartphone-based self-management support system for dialysis patients. METHODS: We developed the Self-Management and Recording System for Dialysis (SMART-D), which supports self-monitoring of three mortality-related factors that can be modified by lifestyle: interdialytic weight gain and predialysis serum potassium and phosphorus concentrations. Data is displayed graphically, with all data evaluated automatically to determine whether they achieve the values suggested by the Japanese Society for Dialysis Therapy guidelines. In a pilot study, 9 dialysis patients used SMART-D system for 2 weeks. A total of 7 of them completed questionnaires rating their assessment of SMART-D's usability and their satisfaction with the system. In addition, the Kidney Disease Quality of Life scale was compared before and after the study period. RESULTS: All 9 participants were able to use SMART-D with no major problems. Completion rates for body weight, pre- and postdialysis weight, and serum potassium and phosphorus concentrations were, respectively, 89% (SD 23), 95% (SD 7), and 78% (SD 44). Of the 7 participants who completed the usability survey, all were motivated by the sense of security derived from using the system, and 6 of the 7 (86%) reported that using SMART-D helped improve their lifestyle and self-management. CONCLUSIONS: Using SMART-D was feasible, and the system was well regarded by patients. Further study with larger scale cohorts and longer study and follow-up periods is needed to evaluate the effects of SMART-D on clinical outcomes and quality of life.

Coronary spasm is abnormal contraction of an epicardial coronary artery resulting in myocardial ischemia. Coronary spasm induces not only depressed myocardial contractility, but also incomplete myocardial relaxation, which leads to elevated ventricular filling pressure. We herein report the case of a 55-year-old woman who had repeated acute heart failure caused by coronary spasm. Acetylcholine provocation test with simultaneous right heart catheterization was useful for the diagnosis of elevated ventricular filling pressure as well as coronary artery spasm. We should add coronary spasm to a differential diagnosis for repeated acute heart failure.

Objectives: The purpose of this randomized trial was to compare the incidence of slow flow between low-speed and high-speed rotational atherectomy (RA) of calcified coronary lesions. Background: Preclinical studies suggest that slow flow is less frequently observed with low-speed than high-speed RA because of less platelet aggregation with low-speed RA. Methods: This was a prospective, randomized, single center study. A total of 100 patients with calcified coronary lesions were enrolled and randomly assigned in a 1:1 ratio to low-speed (140,000 rpm) or high-speed (190,000 rpm) RA. The primary endpoint was the occurrence of slow flow following RA. Slow flow was defined as slow or absent distal runoff (Thrombolysis in Myocardial Infarction [TIMI] flow grade2). Results: The incidence of slow flow in the low-speed group (24%) was the same as that in the high-speed group (24%) (P=1.00; odds ratio, 1.00; 95% confidence interval, 0.40-2.50). The frequencies of TIMI 3, TIMI 2, TIMI 1, and TIMI 0 flow grades were similar between the low-speed (TIMI 3, 76%; TIMI 2, 14%; TIMI 1, 8%; TIMI 0, 2%) and high-speed (TIMI 3, 76%; TIMI 2, 14%; TIMI 1, 10%; TIMI 0, 0%) groups (P=0.77 for trend). The incidence of periprocedural myocardial infarction was the same between the low-speed (6%) and high-speed (6%) groups (P=1.00). Conclusions: This randomized trial did not show a reduction in the incidence of slow flow following low-speed RA as compared with high-speed RA (UMIN ID: UMIN000015702). (c) 2016 Wiley Periodicals, Inc.

hi rotational atherectomy (RA), several burr sizes are available, such as 1.25 mm, 1.5 mm, 1.75 mm, or &gt;= 2.0 mm. It is important to select an appropriate bun size for each lesion because rotational atherectomy has several unique complications regarding burrs such as entrapment or perforation. When a burr cannot penetrate the lesion, downsizing of the burr is generally recommended. Also, if the smallest burr (1.25 mm) cannot penetrate the lesion, a change to a more supportive or larger French guiding catheter has been recommended. We describe the case of a 68 year-old female who was referred to our department for percutaneous coronary intervention to the calcified stenosis in the middle of the left anterior descending coronary artery. We used the smallest burr (1.25 mm) and a supportive 7 Fr guiding catheter to penetrate the lesion. However, the smallest burr could not pass the lesion even after 14 sessions (total ablation time: 339 seconds). We intentionally increased the burr size from 1.25 mm to 1.5 mm. The 1.5 mm burr successfully passed the lesion without any perforation or burr entrapment. In this manuscript, we discuss why increasing the burr size was successful for this severely calcified lesion that was not penetrated by the smallest burr.

<p>Acute symptomatic deep vein thrombosis (DVT) is usually managed by intravenous heparin and oral warfarin. Recently, direct oral anticoagulants (DOAC) have been introduced for the treatment of acute DVT. DOAC may be useful for very elderly patients who live in rural areas, where medical resources are limited. An 83-year-old woman presented to our clinic with left leg edema. Contrast enhanced computed tomography showed massive deep vein thrombosis in her left internal iliac vein. We diagnosed her with acute deep vein thrombosis. Since she refused to be hospitalized, we treated her with rivaroxaban as an outpatient. She had a good clinical course without hospitalization or an adverse event. DOAC may be useful for very elderly patients in rural areas.</p>

OBJECTIVES: To examine the prevalence of the willingness of patients with diabetes to use a self-management tool based on information and communication technology (ICT) such as personal computers, smartphones, and mobile phones; and to examine the patient characteristics associated with that willingness. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional interview survey of 312 adults with diabetes at a university hospital in an urban area in Japan. Participants were classified into 2 groups: those who were willing to use an ICT-based self-management tool and those who were unwilling. Multiple logistic regression analysis was used to identify factors associated with the willingness, including clinical and social factors, current use of ICT, self-management practices, self-efficacy, and diabetes-related emotional distress. RESULTS: The mean age of the 312 participants was 66.3 years (SD=11.5) and 198 (63%) were male. Most of the participants (93%) had type 2 diabetes. Although only 51 (16%) currently used ICT-based self-management tools, a total of 157 (50%) expressed the willingness to use such a tool. Factors associated with the willingness included: not having nephropathy (OR=2.02, 95% CI 1.14 to 3.58); outpatient visits once a month or more (vs less than once a month, OR=2.13, 95% CI 1.13 to 3.99); current use of personal computers and/or smartphones (OR=4.91, 95% CI 2.69 to 8.98); and having greater diabetes-related emotional distress (OR=1.10, 95% CI 1.01 to 1.20). CONCLUSIONS: Approximately half of the patients showed interest in using an ICT-based self-management tool. Willing patients may expect ICT-based self-management tools to complement outpatient visits and to make self-management easier. Starting with patients who display the willingness factors might optimize programs based on such tools.

Eosinophilic myocarditis is a rare form of myocardial inflammation that is characterized by the infiltration of eosinophilic cells into the myocardium. The clinical symptoms of eosinophilic myocarditis are similar to those of acute coronary syndrome, and eosinophilic myocarditis sometimes occurs in combination with bronchial asthma. We herein present a case of eosinophilic myocarditis in which additional time was required to make a definitive diagnosis because the patient received steroid therapy. The diagnosis of eosinophilic myocarditis is challenging, especially when a patient has other inflammatory diseases, such as bronchial asthma. We should pay attention to the possibility that steroid therapy may mask the presentation of eosinophilic myocarditis.

Compared to acute myocardial infarction (AMI) with single vessel disease (SVD) or double vessel disease (DVD), AMI with triple vessel disease (TVD) is associated with higher mortality. The aim of this study was to identify the determinants of in-hospital death in AMI with TVD. We identified AMI patients with TVD in our tertiary medical center between January 2009 and December 2014. Baseline patient characteristics including laboratory data, echocardiograms, and coronary angiograms were collected from our hospital records. We divided our study population into a survivor group and non-survivor group. Multivariate stepwise logistic regression analysis was performed to identify the determinants of in-hospital death. A total of 138 AMI patients with TVD were identified and included as the final study population. Fifteen patients died during the hospitalization (mortality rate, 10.9%). Mean systolic blood pressure (134 ± 27 mmHg) was significantly greater in the survivor group compared with the non-survivor group (114 ± 31 mmHg) (P = 0.02). The prevalence of shock on admission was significantly less in the survivor group (15.4%) than in the non-survivor group (66.7%) (P < 0.001). Multivariate stepwise logistic regression analysis revealed that shock status on admission (OR 11.50, 95% CI 3.21-41.14, P < 0.001), the left anterior descending artery (LAD) as the infarct related artery (IRA) (OR 3.83, 95% CI 1.04-14.09, P = 0.04), and serum albumin on admission (OR 0.26, 95% CI 0.08-0.84, P = 0.02) were significantly associated with in-hospital death. In conclusion, shock status on admission, the LAD as the IRA, and a low serum albumin level were the determinants of in-hospital death in AMI patients with TVD.

BACKGROUND: The usage of rotational atherectomy (RA) is growing in the current percutaneous coronary intervention (PCI) because of the expansion of PCI indication to more complex lesions. However, the complications after RA have been linked to procedure-related morbidity and mortality. The purpose of this study was to investigate the incidence and determinants of complications in RA using a large nationwide registration system in Japan (J-PCI). METHODS AND RESULTS: The primary composite outcome of this study was defined as the occurrence of in-hospital death, cardiac tamponade, and emergent surgery after RA. A total of 13 335 RA cases (3.2% of registered PCI cases) were analyzed. The composite outcome was observed in 175 cases (1.31%) and included 80 in-hospital deaths (0.60%), 86 tamponades (0.64%), and 24 emergent surgeries (0.18%). The clinical variables associated with occurrence of the composite outcome were age (odds ratio [OR] 1.03 per unit increment, 95% confidence interval [CI] 1.02-1.05), impaired kidney function (OR 1.59, 95% CI 1.15-2.19), previous myocardial infarction (OR 1.69, 95% CI 1.21-2.35), emergent PCI (OR 4.02, 95% CI 1.66-8.27), and triple-vessel disease (versus single-vessel disease: OR 2.17, 95% CI 1.43-3.28). Notably, institutional volume of RA cases was inversely associated with the composite outcomes (high- versus low-volume institution: OR 0.56, 95% CI 0.36-0.89). CONCLUSIONS: The reported incidence of important procedure-related complication rate was 1.3%, with each component ranging between 0.2% and 0.6% in J-PCI. Its determinants were both patient related (age, impaired kidney function, and previous myocardial infarction) and procedure related (emergent procedures, number of diseased vessels, and institutional volume of RA).

Background: The accuracy of estimating nutritional intake and balance from photos of meals has not been well documented. However, DialBetics (DB)—our diabetes self-management support system, which is based on information and communication technologies—relies on the photos that type 2 diabetes patients take of their meals with smartphones. Therefore, we designed a study to evaluate this accuracy. Methods: We prepared 61 dishes whose actual amount/value of total energy and each nutrient were known: protein, fat, carbohydrates, dietary fiber and salt. Their balance—the protein-fat-carbohydrate ratio—was also known, constituting the weighed food record (WFR). Smartphone photos of those dishes were taken, and three registered dietitians evaluated each dish from those photos, naming the dish and estimating the amount of each nutrient in it, plus the dish’s balance. These estimated DB and WFR values were compared using the Wilcoxon matched-pairs rank-sum test intraclass correlation coefficients (ICCs) were calculated. Agreement between the two values for each dish was assessed by Bland-Altman analysis. Results: There were significant ICCs—0.84 for fat (95 % confidence interval 0.75–0.90) and 0.93 for carbohydrates (0.88, 0.96)—but no statistically significant differences between DB and WRF for other nutrients or balance. Bland-Altman analysis showed that differences between the two values were random and not biased against nutrient intake 95 % limits of agreement were acceptable although wide (energy −198 to 210 kcal/dish carbohydrates −22.7 to 25.8 g/dish). Conclusion: DB’s diet evaluation by photos is reliable with apparent potential for assessing diets.

Revascularization therapy such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) should be considered for heart failure with reduced ejection fraction (HFrEF). However, revascularization therapy does not always improve left ventricular ejection fraction (LVEF). The purpose of this study was to investigate the determinants of LVEF improvement following revascularization in HFrEF patients. From 2,229 consecutive decompensated heart failure patients, a total of 47 HFrEF patients who underwent revascularization were included in the analysis. Improvement of LVEF was defined as [(LVEF during chronic phase) - (LVEF during acute phase)] &gt;= 10%. Univariate and multivariate logistic regression analyses were applied to investigate the determinants of LVEF improvement. The prevalence of revascularization by PCIs including chronic total occlusion (CTO) was significantly greater in the improved EF group (45.0%) as compared to the non -improved EF group (11.1%) (P = 0.02). Multivariate logistic regression analysis revealed that revascularization by PCIs including CTO was the significant determinant of the LVEF improvement after adjusting for confounding factors (OR 5.43, 95% CI 1.06-27.74, P = 0.04). Optimal medical therapy (angiotensin-converting enzyme (ACE) inhibitor and/or angiotensin II receptor blocker (ARB) and beta-blockers) was less frequently prescribed in patients with CABG (50.0% for ACE inhibitor and/or ARB and 41.7% for beta-blocker) than in patients without CABG (94.3% for both) (P &lt; 0.01 and P &lt; 0.001, respectively). In conclusion, revascularization by PCIs including CTO was the significant determinant of LVEF improvement in HFrEF patients. Our results underscore the importance of optimal medical therapy even if patients receive complete revascularization such as CABG.

Background: Prolonged fluoroscopy time during coronary angiography is a major concern for interventional cardiologists as well as for patients. It is unknown which factors affect the prolonged fluoroscopy time. Methods: A total of 458 patients who underwent diagnostic coronary angiography were included. The patients who had the highest decile of fluoroscopy time were assigned to the prolonged fluoroscopy group (fluoroscopy time &gt;= 15.7 min), while the other patients were assigned to the non -prolonged fluoroscopy group (fluoroscopy time &lt;15.7 min). We performed univariate and multivariate logistic regression analysis to identify the predictors of prolonged fluoroscopy time. Results: Mean fluoroscopy time in 458 patients was 8.5 +/- 5.8 min. Median and ranges of fluoroscopy time were 19.0 [15.7-47.0] min in the prolonged fluoroscopy group and 6.0 [2.0-15.3] min in the non -prolonged fluoroscopy group, respectively. The multivariate logistic regression analysis showed that significant predictors of prolonged fluoroscopy time were prior surgery of ascending aorta replacement [odds ratios (OR) 11.46, 95% confidence intervals (CI) 1.53-85.74, p = 0.02] and the prevalence of moderate to severe aortic regurgitation (OR 2.83, 95% CI 1.20-6.66, p = 0.02). Conclusions: The prior surgery of ascending aorta replacement and moderate to severe aortic regurgitation were significant predictors of the prolonged fluoroscopy time. (C) 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Rotational atherectomy to an angulated calcified lesion is always challenging. The risk of catastrophic complications such as a burr becoming stuck or vessel perforation is greater when the calcified lesion is angulated. We describe the case of an 83-year-old female suffering from unstable angina. Diagnostic coronary angiography revealed an angulated calcified lesion in the proximal segment of the right coronary artery. We performed rotational atherectomy to the lesion, but intentionally did not advance the rotational atherectomy burr beyond the top of the angulation. We controlled the rotational atherectomy burr and stopped it just before the top of the angulation to avoid complications. Following rotational atherectomy, balloon dilatation with a non-compliant balloon was performed, and drug-eluting stents were successfully deployed. In this manuscript, we provide a review of the literature on this topic, and discuss how rotational atherectomy to an angulated calcified lesion should be performed.

Background: Compared to transpulmonary pressure gradient (TPPG), diastolic pulmonary vascular pressure gradient (DPG) may be a more sensitive and specific indicator for pulmonary hypertension (PH) due to left heart disease (LHD) with significant pulmonary vascular disease (PVD). The aim of this study was to investigate the incidence and clinical features of PH-LHD with PVD classified by DPG and TPPG. Methods: We analyzed 410 patients admitted for symptomatic heart failure (HF) (New York Heart Association &gt;= 2) and who underwent right heart catheterization (RHC) at compensated stage between 2007 and 2012. Patients with PH-LHD were divided into 3 groups according to the value of DPG and TPPG (Non-PVD group: DPG &lt;7 mmHg and TPPG &lt;= 12 mmHg; TPPG-PVD group: DPG &lt;7 mmHg and TPPG &gt;12 mmHg; DPG-PVD group: DPG &gt;= 7 mmHg). Multivariate Cox regression analysis was applied to investigate whether each PH-LHD category predicts death or HF readmission after adjusting for other variables. Results: PH-LHD was observed in 164 patients (40%) with symptomatic HF. Thirteen patients (3%) were allocated into DPG-PVD group, while 24 patients were allocated into TPPG-PVD group (6%). DPG-PVD group was significantly associated with death or HF readmission compared to non-PVD group (hazard ratio: 3.57; 95% CI: 1.33 to 9.55, p = 0.01), while the association between TPPG-PVD group and non-PVD group did not reach statistical significance (hazard ratio: 1.89; 95% CI: 0.77 to 4.64, p = 0.17). Conclusions: PH-LHD with PVD classified by DPG was significantly associated with poor long-term clinical outcomes, whereas the association between PH-LHD with PVD classified by TPPG and clinical outcomes did not reach statistical significance. However, further studies are needed, because there was no substantial difference in clinical outcomes between PH-LHD with PVD classified by DPG and PH-LHD with PVD classified by TPPG. (C) 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.