Publications by authors named "Takahiro Okumura"

130 Publications

Prognostic Implications of Reductions in Heart Rates in Patients With Acute Heart Failure and Atrial Fibrillation.

Circ J 2021 Jul 9. Epub 2021 Jul 9.

Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine.

Background: Atrial fibrillation (AF) is a common arrhythmia in patients with acute heart failure (AHF). Heart rate (HR) also changes significantly over time. However, the association between changes in HR in AF patients and prognosis is uncertain.Methods and Results:We investigated the association between HR reduction in AF achieved within 48 h of admission and 60-day mortality in patients with AHF from the REALITY-AHF study. The percentage HR (%HR) reduction was calculated as (baseline HR-HR at 48 h) / baseline HR × 100. The primary endpoint was 60-day all-cause mortality. In 468 patients with confirmed AF at both admission and 48 h after admission, the median HR at these time points was 105±31 and 84±18 beats/min, respectively. The median %HR reduction was 15.4% (interquartile range 2.2-31.4%). During the 60 days of admission, 39 deaths (8.3%) were recorded, and the %HR reduction within 48 h was significantly associated with 60-day mortality in the unadjusted model (hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.77-0.95; P=0.005) and after adjusting for other covariates (HR 0.81; 95% CI 0.68-0.96; P=0.016).Furthermore, the %HR reduction was associated with a significant reduction in 60-day mortality in patients with higher baseline HR.

Conclusions: %HR reduction is associated with a better short-term prognosis in patients with AHF presenting with AF, particularly in those with a rapid ventricular response.
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http://dx.doi.org/10.1253/circj.CJ-21-0269DOI Listing
July 2021

Prognostic impact of immune-related adverse events on patients with and without cardiovascular disease: a retrospective review.

Cardiooncology 2021 Jul 6;7(1):26. Epub 2021 Jul 6.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.

Background: The emergence of immune checkpoint inhibitors (ICIs) has brought about a paradigm shift in cancer treatment as the use of these drugs has become more frequent and for a longer duration. As a result of T-cell-mediated inflammation at the programmed cell death-1, programmed death-ligand-1, and cytotoxic T-lymphocyte antigen-4 pathways, immune-related adverse events (irAEs) occur in various organs and can cause a rare but potentially induced cardiotoxicity. Although irAEs are associated with the efficacy of ICI therapy and better prognosis, there is limited information about the correlation between irAEs and cardiotoxicity and whether the benefits of irAEs apply to patients with underlying cardiovascular disease. This study aimed to investigate the association of irAEs and treatment efficacy in patients undergoing ICI therapy with and without a cardiovascular history.

Methods: We performed a retrospective review of the medical records of 409 consecutive patients who received ICI therapy from September 2014 to October 2019.

Results: Median patient age was 69 years (29.6% were female). The median follow-up period was 278 days. In total, 69 (16.9%) patients had a history of any cardiovascular disease and 14 (3.4%) patients experienced cardiovascular irAEs after ICI administration. The rate of cardiovascular irAEs was higher in patients with prior non-cardiovascular irAEs than without. The prognosis of patients with irAEs ( +) was significantly better than that of the patients without irAEs (P < 0.001); additionally, this tendency did not depend on the presence or absence of a cardiovascular history. Furthermore, the Cox proportional hazards analysis revealed that irAEs were an independent predictor of mortality.

Conclusions: Although cardiovascular irAEs may be related to prior non-cardiovascular irAEs under ICI therapy, the occurrence of irAEs had a better prognostic impact and this tendency was not affected by cardiovascular history.
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http://dx.doi.org/10.1186/s40959-021-00112-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259377PMC
July 2021

Prognostic relevance of elevated plasma osmolality on admission in acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry.

BMC Cardiovasc Disord 2021 Jun 7;21(1):281. Epub 2021 Jun 7.

Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan.

Background: Complicated pathophysiology makes it difficult to identify the prognosis of heart failure with preserved ejection fraction (HFpEF). While plasma osmolality has been reported to have prognostic importance, mainly in heart failure with reduced ejection fraction (HFrEF), its prognostic meaning for HFpEF has not been elucidated.

Methods: We prospectively studied 960 patients in PURSUIT-HFpEF, a multicenter observational study of acute decompensated HFpEF inpatients. We divided patients into three groups according to the quantile values of plasma osmolality on admission. During a follow-up averaging 366 days, we examined the primary composite endpoint of cardiac mortality or heart failure re-admission using Kaplan-Meier curve analysis and Cox proportional hazard testing.

Results: 216 (22.5%) patients reached the primary endpoint. Kaplan-Meier curve analysis revealed that the highest quantile of plasma osmolality on admission (higher than 300.3 mOsm/kg) was significantly associated with adverse outcomes (Log-rank P = 0.0095). Univariable analysis in the Cox proportional hazard model also revealed significantly higher rates of adverse outcomes in the higher plasma osmolality on admission (hazard ratio [HR] 7.29; 95% confidence interval [CI] 2.25-23.92, P = 0.0009). Multivariable analysis in the Cox proportional hazard model also showed that higher plasma osmolality on admission was significantly associated with adverse outcomes (HR 5.47; 95% CI 1.46-21.56, P = 0.0113) independently from other confounding factors such as age, gender, comorbid of atrial fibrillation, hypertension history, diabetes, anemia, malnutrition, E/e', and N-terminal pro-B-type natriuretic peptide elevation.

Conclusions: Higher plasma osmolality on admission was prognostically important for acute decompensated HFpEF inpatients.
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http://dx.doi.org/10.1186/s12872-021-02098-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182926PMC
June 2021

Multidisciplinary Approaches for Transthyretin Amyloidosis.

Cardiol Ther 2021 Jun 4. Epub 2021 Jun 4.

Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Amyloidosis caused by systemic deposition of transthyretin (TTR) is called ATTR amyloidosis and mainly includes hereditary ATTR (ATTRv) amyloidosis and wild-type ATTR (ATTRwt) amyloidosis. Until recently, ATTRv amyloidosis had been considered a disease in the field of neurology because neuropathic symptoms predominated in patients described in early reports, whereas advances in diagnostic techniques and increased recognition of this disease revealed the presence of patients with cardiomyopathy as a predominant feature. In contrast, ATTRwt amyloidosis has been considered a disease in the field of cardiology. However, recent studies have suggested that some of the patients with ATTRwt amyloidosis present tenosynovial tissue complications, particularly carpal tunnel syndrome, as an initial manifestation of amyloidosis, necessitating an awareness of this disease among neurologists and orthopedists. Although histopathological confirmation of amyloid deposits has traditionally been considered mandatory for the diagnosis of ATTR amyloidosis, the development of noninvasive imaging techniques in the field of cardiology, such as echocardiography, magnetic resonance imaging, and nuclear imaging, enabled nonbiopsy diagnosis of this disease. The mechanisms underlying characteristic cardiac imaging findings have been deciphered by histopathological studies. Novel disease-modifying therapies for ATTR amyloidosis, such as TTR stabilizers, short interfering RNA, and antisense oligonucleotides, were initially approved for ATTRv amyloidosis patients with polyneuropathy. However, the indications for the use of these disease-modifying therapies gradually widened to include ATTRv and ATTRwt amyloidosis patients with cardiomyopathy. Since the coronavirus disease 2019 (COVID-19) pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, occurred, the minimization of hospital visits and telemedicine have become increasingly important. As older age and cardiovascular disease are major factors associated with increased disease severity and mortality of COVID-19, many ATTR amyloidosis patients are at increased risk of disease aggravation when they are infected with SARS-CoV-2. From this viewpoint, close interspecialty communication to determine the optimal interval of evaluation is needed for the management of patients with ATTR amyloidosis.
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http://dx.doi.org/10.1007/s40119-021-00222-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177037PMC
June 2021

Prognostic value of resting cardiac power index depends on mean arterial pressure in dilated cardiomyopathy.

ESC Heart Fail 2021 May 27. Epub 2021 May 27.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.

Aims: In recent decades, haemodynamic parameters have been estimated for risk stratification and determining treatment strategies for patients with non-ischaemic dilated cardiomyopathy (DCM). In various invasive procedures, the cardiac pumping capability is defined as cardiac power output (CPO), which is calculated by multiplying cardiac output by the mean arterial pressure. Lower CPO values in advanced heart failure predict adverse outcomes. However, few studies discuss the prognostic value of CPO in mild-to-moderate phase patients. This study aimed to determine the value of the cardiac power index (CPI) obtained from the resting CPO for predicting the prognosis of patients with New York Heart Association Functional Class II or III DCM.

Methods And Results: From March 2000 to January 2020, a total of 623 cardiomyopathy patients were evaluated for haemodynamic parameters. Patients with secondary cardiomyopathy, ischaemic cardiomyopathy, valvular heart disease, and Class IV cardiomyopathy were excluded. A total of 176 DCM patients fulfilled the criteria for inclusion. Patients were 51.7 ± 12.5 years old (mean ± standard deviation) with a mean left ventricular ejection fraction of 32.1 ± 9.2%. The patients were divided into two groups by their median CPI (CPI < 0.52, low-CPI; CPI ≥ 0.52, high-CPI). No significant differences were found in the left ventricular end-diastolic diameter, left ventricular ejection fraction, or pulmonary arterial wedge pressure between the groups. The probability of cardiac event-free survival was significantly lower for low-CPI than for high-CPI groups by Kaplan-Meier analysis (P = 0.012), even with no significant difference between the high and low cardiac index groups (P = 0.069). Furthermore, Cox proportional hazards regression analysis revealed that, in addition to the CPI, the systolic and mean arterial pressure involved in CPI calculation were independent predictors of cardiac events. Indeed, among these factors, mean arterial pressure had the strongest prognostic ability.

Conclusions: Although CPI is effective for stratifying DCM and predicting cardiac events in patients with Class II/III DCM, this prognostic value depends on mean arterial pressure.
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http://dx.doi.org/10.1002/ehf2.13446DOI Listing
May 2021

Heart Failure Association, Heart Failure Society of America, and Japanese Heart Failure Society Position Statement on Endomyocardial Biopsy.

J Card Fail 2021 Jul 19;27(7):727-743. Epub 2021 May 19.

Cleveland Clinic, Cleveland Ohio.

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumors. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples has significantly improved the diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (1) an overview of the practical approach to EMB, (2) an update on indications for EMB, (3) a revised plan for heart transplant rejection surveillance, (4) the impact of multimodality imaging on EMB, and (5) the current clinical practice in the worldwide use of EMB.
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http://dx.doi.org/10.1016/j.cardfail.2021.04.010DOI Listing
July 2021

Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy.

Eur J Heart Fail 2021 Jun 19;23(6):854-871. Epub 2021 May 19.

Cleveland Clinic, Cleveland, OH, USA.

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant (HTx) rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples have significantly improved diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (i) an overview of the practical approach to EMB, (ii) an update on indications for EMB, (iii) a revised plan for HTx rejection surveillance, (iv) the impact of multimodality imaging on EMB, and (v) the current clinical practice in the worldwide use of EMB.
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http://dx.doi.org/10.1002/ejhf.2190DOI Listing
June 2021

Distinctive prognostic factor of heart failure with preserved ejection fraction stratified with admission blood pressure.

ESC Heart Fail 2021 May 16. Epub 2021 May 16.

Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan.

Aims: The prognostic importance of admission systolic blood pressure (SBP) in heart failure with preserved ejection fraction (HFpEF) is elusive. We aimed to clarify the pathophysiological differences between patients categorized with admission SBP among HFpEF patients.

Methods And Results: We studied 1008 inpatients from PURSUIT-HFpEF, a multicentre prospective observational registry. We classified patients as having elevated (>140 mmHg), preserved (90-140 mmHg), or low (<90 mmHg) admission SBP. Most cases had elevated (n = 584) or preserved (n = 420) SBP; the four cases with low SBP were excluded. Univariable Cox regression testing revealed that preserved SBP patients had a higher risk of a composite of cardiac death and heart failure re-hospitalization [hazard ratio (HR) 1.48, 95% confidence interval (CI) 1.14-1.92, P = 0.0035] than elevated SBP patients. In multivariable Cox regression models, while prior heart failure hospitalization (HR 1.36, 95% CI 1.01-2.84, P = 0.0453), atrial fibrillation (HR 1.82, 95% CI 1.10-2.99, P = 0.0209), and N-terminal pro-B-type natriuretic peptide (HR 1.94, 95% CI 1.10-3.43, P = 0.0229) at discharge were significantly associated with adverse outcomes in elevated SBP patients, N-terminal pro-B-type natriuretic peptide (HR 2.06, 95% CI 1.04-4.07, P = 0.0373) and right ventricular-pulmonary artery uncoupling reflected by the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio (HR 0.19, 95% CI 0.05-0.65, P = 0.0075) at discharge were significant prognostic factors in preserved SBP patients.

Conclusions: Patients with preserved admission SBP had significant higher risks for adverse outcomes than those with elevated SBP in HFpEF. Tricuspid annular plane systolic excursion/pulmonary artery systolic pressure was the distinctive prognostic factor between the two groups.
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http://dx.doi.org/10.1002/ehf2.13420DOI Listing
May 2021

Clinical impact of heart rate change in patients with acute heart failure in the early phase.

ESC Heart Fail 2021 May 2. Epub 2021 May 2.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.

Aims: Patients with acute heart failure (AHF) often present with an increased heart rate (HR), and the HR changes dramatically after initial treatment for AHF. However, the HR change after admission and the relationship between HR change in the early phase and prognosis have not been fully elucidated.

Methods And Results: From a multicentre AHF registry, we retrospectively evaluated 1527 consecutive patients admitted with AHF. HR change (%) was calculated by [HR (at admission) - HR (24 h after admission)] × 100∕HR (at admission). The median HR change was 15.1% (range, 2.0-28.4%). The HR decreased most in the first 24 h and then gradually thereafter [admission: 98 (81-117) b.p.m., 24 h: 80 (70-92) b.p.m., 48 h: 78 (68-90) b.p.m., and 72 h: 77 (67-88) b.p.m.]. In Kaplan-Meier analysis, the cumulative event-free rates in the composite endpoint of death and rehospitalization due to AHF showed better according to larger HR change (P = 0.012, log rank). Cox proportional hazards analysis showed that HR change was a prognostic factor for composite endpoint adjusted by age and sex [hazard ratio, 0.995; 95% confidence interval (CI), 0.991-0.998; P = 0.006]. HR change was associated with outcome adjusted by age and sex in patients with sinus rhythm (hazard ratio, 0.993; 95% CI, 0.988-0.999; P = 0.015), but not in patients with atrial fibrillation (hazard ratio, 0.996; 95% CI, 0.990-1.002; P = 0.15).

Conclusions: A decrease in HR in the first 24 h after admission indicates better prognosis in patients with AHF, although the prognostic influence may differ between patients with sinus rhythm and those with atrial fibrillation.
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http://dx.doi.org/10.1002/ehf2.13388DOI Listing
May 2021

Two cases of dilated cardiomyopathy with blood pressure-limited tolerability of cardioprotective agents improved by ivabradine.

J Cardiol Cases 2021 Apr 23;23(4):149-153. Epub 2020 Nov 23.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8560, Japan.

The titration of cardioprotective agents is essential for successful treatment of heart failure (HF) patients with reduced left ventricular ejection fraction. However, hypotension is one of the limiting factors for titration. Ivabradine reduces heart rate without compromising systolic function by prolonging diastolic filling time. Herein two cases of dilated cardiomyopathy (DCM) are presented in which ivabradine improved blood pressure (BP)-limited tolerability and allowed for further titration of cardioprotective agents. In both cases, the introduction of ivabradine raised the BP, which permitted further increase of the dose of renin-angiotensin system inhibitors or beta-blockers. One major hypothesized mechanism of ivabradine-induced BP elevation has been postulated to be an increase in stroke volume due to prolonged ventricular diastolic filling time. However, ivabradine is not expected to increase BP for all HF patients. In those with small and poorly compliant ventricles with severe diastolic or restricted dysfunction, decreased heart rate and prolonged diastole may excessively suppress compensatory mechanisms, and thus may not lead to increased cardiac output and BP. In contrast, ivabradine potentially increases BP and improves BP-limited tolerability of cardioprotective agents in DCM patients with a large and compliant heart. In addition, subsequent titration of cardioprotective agents may provide additional cardiac reverse remodeling. Learning objective: Ivabradine is usually used for heart failure patients with reduced ejection fraction when the tolerability of cardioprotective agents is maximized. This agent has no direct cardiac contractility-suppressing action. It potentially increases blood pressure and improves tolerability of cardioprotective agents in patients with a large and compliant heart such as dilated cardiomyopathy. Furthermore, subsequent titration of cardioprotective agents may provide additional cardiac reverse remodeling.
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http://dx.doi.org/10.1016/j.jccase.2020.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020064PMC
April 2021

A case of heart failure complicated with double ventricular response triggered by beta blocker.

HeartRhythm Case Rep 2021 Mar 17;7(3):174-177. Epub 2020 Dec 17.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

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http://dx.doi.org/10.1016/j.hrcr.2020.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987924PMC
March 2021

High-output Heart Failure Caused by a Tumor-related Arteriovenous Fistula: A Case Report and Literature Review.

Intern Med 2021 Mar 29. Epub 2021 Mar 29.

Department of Cardiology, Nagoya University Graduate School of Medicine, Japan.

High-output heart failure caused by a tumor-related arteriovenous fistula in adults is a rare clinical condition. We herein report a case of high-output heart failure caused by an arteriovenous fistula associated with renal cell carcinoma and a literature review of 29 published cases to date. Renal cell carcinoma seems to be the most common underlying tumor. For the diagnosis, right heart catheterization and enhanced computed tomography are considered useful. The removal of the underlying tumor and arteriovenous fistula is the best treatment for heart failure.
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http://dx.doi.org/10.2169/internalmedicine.6962-20DOI Listing
March 2021

Ten-Year Mortality in Patients With ST-Elevation Myocardial Infarction.

Am J Cardiol 2021 06 20;149:9-15. Epub 2021 Mar 20.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Knowledge of the long-term prognosis (>10 years) and mortality predictors of ST-elevation myocardial infarction (STEMI) patients who have undergone primary percutaneous coronary intervention (p-PCI) is scarce. Therefore, this study evaluated the long-term prognosis and determined the predictors of long-term outcomes for STEMI patients after p-PCI. Between January, 2006 and December, 2010, we collected data and analyzed 459 consecutive patients with acute STEMI who underwent p-PCI and were discharged from the hospital (mean age, 66.8 years; male, 75.2%; peak creatine phosphokinase level, 2,292.5 IU/L). The primary endpoint was 10-year all-cause mortality. The cumulative 10-year incidence of all-cause death was 23.8%. The Cox multivariate regression analysis identified age ≥ 65 years (adjusted hazard ratio [aHR], p <0.001), body mass index (aHR, 0.93, p = 0.033), presence of atrial fibrillation (aHR, 1.69, p = 0.038), mineralocorticoid receptor antagonist use (aHR, 1.95, p = 0.008), ejection fraction <40% (aHR, 2.14, p = 0.005), and albumin <3.5 g/dL (aHR, 2.01, p = 0.005) as independent predictors of all-cause mortality. In conclusion, a post-discharge 10-year survival rate of 76.2% was identified for STEMI patients who underwent p-PCI.
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http://dx.doi.org/10.1016/j.amjcard.2021.03.008DOI Listing
June 2021

Development of a valve type semi-closed extracorporeal circulation system.

J Artif Organs 2021 Feb 3. Epub 2021 Feb 3.

School of Clinical Engineering, Faculty of Health and Medical Care, Saitama Medical University, 1397-1, Yamane, Hidaka, Saitama, 350-1241, Japan.

In Japan, perfusionists who work on other clinical tasks are involved in cardiopulmonary bypass. Moreover, the number of cases they can perform is limited. In view of this situation, valve type semi-closed extracorporeal circulation (VACC) was developed as a system that enables extracorporeal circulation (ECC) regardless of perfusionists' experience. The VACC circuit is based on a conventional open-type ECC circuit. A safety valve is installed at the outlet of the reservoir. It is closed by lowering the reservoir pressure below the venous circuit pressure (Pv), thereby providing a closed-type ECC in which the reservoir is separated from the venous circuit (V-circuit). A closed-type ECC needs means to cope with negative pressure generated in the V-circuit and to remove air mixed in the V-circuit. Water experiments to verify the safety of the VACC were conducted. In experiments simulating low venous return, when the Pv dropped, the safety valve opened so that the V-circuit was connected to the reservoir, and the excessive negative pressure was relieved. In the VACC circuit, a bubble trap is installed in the V-circuit, and the air is degassed to the reservoir by a roller pump (D-pump). A water experiment was conducted to verify the principle of the constant degassing method using the D-pump. It verified that the blood storage volume could be maintained constant even if the D-pump is continuously driven. The VACC system provides handling of air mixed in the V-circuit and safety in the case of low venous return.
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http://dx.doi.org/10.1007/s10047-021-01249-5DOI Listing
February 2021

Prognostic value of leucine/phenylalanine ratio as an amino acid profile of heart failure.

Heart Vessels 2021 Jul 22;36(7):965-977. Epub 2021 Jan 22.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 466-8550, Japan.

Heart failure (HF) causes a hypercatabolic state that enhances the catabolic activity of branched-chain amino acids (BCAA; leucine, isoleucine, and valine) in the heart and skeletal muscles and reduces protein synthesis in the liver. Consequently, free plasma aromatic amino acids (AAA, tyrosine and phenylalanine) are increased. To date, we have reported the prognostic value of the BCAA/AAA ratio (Fischer's ratio) in patients with HF. However, the leucine/phenylalanine ratio, which is a simpler index than the Fischer's ratio, has not been examined. Therefore, the prognostic value of the leucine/phenylalanine ratio in patients with HF was investigated. Overall 157 consecutive patients hospitalized for worsening HF (81 men, median age 78 years) were enrolled in the study. Plasma amino acid levels were measured when the patients were stabilized at discharge. Cardiac events were defined as a composite of cardiac death and hospitalization for worsening HF. A total of 46 cardiac events occurred during the median follow-up period of 238 (interquartile range 93-365) days. The median leucine/phenylalanine ratio was significantly lower in patients with cardiac events than in those without cardiac events (1.4 vs. 1.8, P < 0.001). The best cutoff value of the leucine/phenylalanine ratio was determined as 1.7 in the receiver operating characteristic (ROC) curve for cardiac events. Following a Kaplan-Meier survival analysis, the low group (leucine/phenylalanine ratio < 1.7, n = 72) had more cardiac events than the high group (leucine/phenylalanine ratio ≥ 1.7, n = 85) (log-rank, P < 0.001). Multivariate Cox proportional hazards regression analysis showed that the leucine/phenylalanine ratio was an independent predictor of cardiac events. Furthermore, on comparing the prognostic values for cardiac events based on ROC curves of leucine levels, BCAA levels, Fischer's ratio, and leucine/phenylalanine ratio, the leucine/phenylalanine ratio was the most accurate in predicting future cardiac events (area under the curve 0.763,; sensitivity 0.783,; specificity 0.676,; P < 0.001). The leucine/phenylalanine ratio could be a useful predictor of future cardiac events in patients with HF, reflecting an imbalance in amino acid metabolism.
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http://dx.doi.org/10.1007/s00380-020-01765-zDOI Listing
July 2021

A clinical score for predicting left ventricular reverse remodelling in patients with dilated cardiomyopathy.

ESC Heart Fail 2021 04 20;8(2):1359-1368. Epub 2021 Jan 20.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.

Aims: Left ventricular reverse remodelling (LVRR) is a well-established predictor of a good prognosis in patients with dilated cardiomyopathy (DCM). The prediction of LVRR is important when developing a long-term treatment strategy. This study aimed to assess the clinical predictors of LVRR and establish a scoring system for predicting LVRR in patients with DCM that can be used at any institution.

Methods And Results: We consecutively enrolled 131 patients with DCM and assessed the clinical predictors of LVRR. LVRR was defined as an absolute increase in left ventricular ejection fraction (LVEF) from ≥10% to a final value of >35%, accompanied by a decrease in left ventricular end-diastolic dimension (LVEDD) ≥ 10% on echocardiography at 1 ± 0.5 years after a diagnosis of DCM. The mean patient age was 50.1 ± 11.9 years. The mean LVEF was 32.2 ± 9.5%, and the mean LVEDD was 64.1 ± 12.5 mm at diagnosis. LVRR was observed in 45 patients (34%) at 1 ± 0.5 years. In a multivariate analysis, hypertension [odds ratio (OR): 6.86; P = 0.002], no family history of DCM (OR: 10.45; P = 0.037), symptom duration <90 days (OR: 6.72; P < 0.001), LVEF <35% (OR: 13.66; P < 0.0001), and QRS duration <116 ms (OR: 5.94; P = 0.005) were found to be independent predictors of LVRR. We scored the five independent predictors according to the ORs (1 point, 2 points, 1 point, 2 points, and 1 point, respectively), and the total LVRR predicting score was calculated by adding these scores. The LVRR rate was stratified by the LVRR predicting score (0-2 points: 0%; 3 points: 6.7%; 4 points: 17.4%; 5 points: 48.2%; 6 points: 79.2%; and 7 points: 100%). The cut-off value of the LVRR predicting score was >5 in receiver-operating characteristic curve analysis (area under the curve: 0.89; P < 0.0001; sensitivity: 87%; specificity: 78%). An LVRR predicting score of >5 was an independent predictor compared with the presence of late gadolinium enhancement on cardiovascular magnetic resonance or the severity of fibrosis on endomyocardial biopsy (OR: 11.79; 95% confidence interval: 2.40-58.00; P = 0.002).

Conclusions: The LVRR predicting score using five predictors including hypertension, no family history of DCM, symptom duration <90 days, LVEF <35%, and QRS duration <116 ms can stratify the LVRR rate in patients with DCM. The LVRR predicting score may be a useful clinical tool that can be used easily at any institution.
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http://dx.doi.org/10.1002/ehf2.13216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006712PMC
April 2021

A case of reexpansion pulmonary edema and acute pulmonary thromboembolism associated with diffuse large B-cell lymphoma treated with venovenous extracorporeal membrane oxygenation.

J Cardiol Cases 2021 Jan 29;23(1):53-56. Epub 2020 Sep 29.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

A 37-year-old man diagnosed with diffuse large B-cell lymphoma two weeks previously, visited our emergency department with sudden dyspnea. He had a severe respiratory failure with saturated percutaneous oxygen at 80% (room air). Chest radiography showed a large amount of left pleural effusion. After 1000 mL of the effusion was urgently drained, reexpansion pulmonary edema (RPE) occurred. Despite ventilator management, oxygenation did not improve and venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated in the intensive care unit. The next day, contrast-enhanced computed tomography showed a massive thrombus in the right pulmonary artery, at this point the presence of pulmonary thromboembolism (PTE) was revealed. Fortunately, the patient's condition gradually improved with anticoagulant therapy and VV-ECMO support. VV-ECMO was successfully discontinued on day 4, and chemotherapy was initiated on day 8. We speculated the following mechanism in this case: blood flow to the right lung significantly reduced due to acute massive PTE, and blood flow to the left lung correspondingly increased, which could have caused RPE in the left lung. Therefore, our observations suggest that drainage of pleural effusion when contralateral blood flow is impaired due to acute PTE may increase the risk of RPE. < This is a case of reexpansion pulmonary edema (RPE) in the left lung following acute pulmonary thromboembolism (PTE) in the right lung associated with malignant lymphoma, managed by venovenous extracorporeal membrane oxygenation. Contralateral pleural drainage could increase the risk of RPE because contralateral pulmonary blood flow is assumed to increase when PTE obstructs blood flow. Pleural drainage should be performed carefully in patients with malignant tumors because PTE may be hidden.>.
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http://dx.doi.org/10.1016/j.jccase.2020.08.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783561PMC
January 2021

Adolescent Kawasaki disease shock syndrome with inflammatory cell infiltration into the myocardium: a case report.

Eur Heart J Case Rep 2020 Oct 9;4(5):1-7. Epub 2020 Sep 9.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8560, Japan.

Background: Kawasaki disease (KD) is a self-limiting form of systemic vasculitis. KD usually occurs in infants and young children and is rarely seen in adolescents. On rare occasions, KD is accompanied with reduced organ perfusion due to systolic hypotension, a condition known as Kawasaki disease shock syndrome (KDSS). The multifactorial causes of KDSS may include intensive vasculitis with capillary leak, myocardial dysfunction, and release of proinflammatory cytokines. However, the mechanisms underlying the pathophysiology of KDSS have not been fully elucidated.

Case Summary: A febrile 17-year-old male with cervical lymphadenopathy developed extreme shock with rapid cardiac dysfunction and reduced organ perfusion. Electrocardiogram revealed ST elevation in the precordial leads and increased serum levels of cardiac enzyme levels. Endomyocardial biopsy at the acute phase revealed CD3, CD4 or CD8, and CD20 lymphocytes and CD68 macrophages within infiltrates in the myocardium with mild interstitial fibrosis. He was treated with intravenous immunoglobulin (IVIG) and followed by glucocorticoids with mechanical circulatory support. His cardiac function recovered rapidly with no apparent adverse effects.

Discussion: Our results suggest that KDSS may be a form of myocarditis, a condition in which inflammatory cells infiltrate the myocardium. Early immunosuppressive therapy, including IVIG and glucocorticoid therapy, may limit the severity of disease and improve the prognosis. As shown by this case, an accurate diagnosis of KD and KDSS will lead to early intervention and improved prognosis even among those in an older cohort.
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http://dx.doi.org/10.1093/ehjcr/ytaa304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649480PMC
October 2020

Prognostic Importance of Right Ventricular-Vascular Uncoupling in Acute Decompensated Heart Failure With Preserved Ejection Fraction.

Circ Cardiovasc Imaging 2020 11 17;13(11):e011430. Epub 2020 Nov 17.

Department of Cardiovascular Medicine (D.N., S.H., Y.S.), Osaka University Graduate School of Medicine, Suita, Japan.

Background: Recent accumulating evidence reveals that the right ventricular (RV)-pulmonary artery (PA) uncoupling is associated with poor outcome in patients with heart failure (HF), RV dysfunction, and pulmonary hypertension. However, the prognostic utility of RV-PA uncoupling in HF with preserved ejection fraction (HFpEF) remains elusive. In this study, we aim to investigate the associations of RV-PA uncoupling with outcomes of HFpEF inpatients.

Methods: We prospectively studied 655 patients, registered in PURSUIT-HFpEF (The Prospective Multicenter Obervational Study of Patients with Heart Failure with Preserved Ejection Fraction), a multicenter observational study of Japanese HFpEF inpatients. We assigned registered patients based on the determined value of tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio that can predict primary outcome as an indicator of RV-PA uncoupling.

Results: Univariable Cox regression testing revealed that RV-PA uncoupling was associated with the primary endpoint of all-cause death, HF rehospitalization, and cerebrovascular events (hazard ratio [HR] 1.77 [95% CI, 1.34-2.32], <0.0001) and the secondary endpoints of all-cause death and HF rehospitalization (HR 2.75 [95% CI, 1.77-4.33], <0.0001, HR 1.63 [95% CI, 1.18-2.26], =0.0036, respectively). Multivariable analysis also showed that RV-PA uncoupling was significantly associated with primary endpoint and all-cause death independent of age, sex, atrial fibrillation, renal dysfunction, elevated E/e', and elevated NT-proBNP (N-terminal pro-B-type natriuretic peptide) (HR 1.38 [95% CI, 1.01-1.88], =0.0413, HR 1.85 [95% CI, 1.14-3.01], =0.0129, respectively).

Conclusions: Prospective study of a hospitalized cohort revealed that RV-PA uncoupling was independently associated with adverse outcomes in acute decompensated patients with HFpEF. Registration: URL: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000024414. Unique identifier: UMIN000021831.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.011430DOI Listing
November 2020

Fulminant myocarditis with myositis of ocular and respiratory muscles.

Nagoya J Med Sci 2020 Aug;82(3):585-593

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

A 46-year-old Japanese woman visited a nearby hospital because of diplopia after flu-like symptoms. One month later, she presented with blepharoptosis and external ophthalmoplegia. Laboratory tests showed a high creatine kinase concentration (3146 U/L). She underwent intravenous immunoglobulin therapy; however, her symptoms did not improve, prompting transfer to our institute. On admission, transthoracic echocardiography revealed 30% of left ventricular ejection fraction and edema of the left ventricular wall. Coronary angiography showed no significant coronary stenosis. An endomyocardial biopsy resulted in a diagnosis of acute myocarditis. On the following day, she needed a temporary pacemaker because she had complete atrioventricular block and intra-aortic balloon pump because of cardiogenic shock. Intravenous immunoglobulin therapy was again administered and her cardiac function gradually recovered. She was successfully weaned off her temporary pacemaker and intra-aortic balloon pump on Day 5 after improvement in her complete atrioventricular block. Steroid therapy administered from Day 9 was effective in reducing her creatine kinase concentrations. However, contrast-enhanced magnetic resonance imaging revealed inflammation of the scalene, semispinalis cervicis, sternocleidomastoid, and intercostal muscles. On Day 25, her cardiac function had recovered to a left ventricular ejection fraction of 59%. Finally, she was successfully discharged on Day 45 after undergoing rehabilitation.
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http://dx.doi.org/10.18999/nagjms.82.3.585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548250PMC
August 2020

Management perspectives from the 2019 Wuhan international workshop on fulminant myocarditis.

Int J Cardiol 2021 02 26;324:131-138. Epub 2020 Oct 26.

Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. Electronic address:

Fulminant myocarditis (FM) is a form of acute myocardial inflammation leading to rapid-onset hemodynamic instability due to cardiogenic shock or life-threatening arrhythmias. As highlighted by recent registries, FM is associated with high rates of death and heart transplantation, regardless of the underlying histology. Because of a paucity of evidence-based management strategies exists for this disease, an International workshop on FM was held in Wuhan, China, in October 2019, in order to share knowledge on the disease and identify areas of consensus. The present report highlights both agreements and controversies in FM management across the world, focusing the attention on areas of opportunity, FM definition, the use of endomyocardial biopsy and viral identification on heart specimens, treatment algorithms including immunosuppression and the timing of circulatory support escalation. This report incorporates the most recent recommendations from national and international professional societies. Main areas of interest and aims of future prospective observational registries and randomized controlled trials were finally identified and suggested.
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http://dx.doi.org/10.1016/j.ijcard.2020.10.063DOI Listing
February 2021

Impact of predictive value of Fibrosis-4 index in patients hospitalized for acute heart failure.

Int J Cardiol 2021 02 30;324:90-95. Epub 2020 Sep 30.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Background: Abnormalities in liver function tests commonly occur in patients with acute heart failure (AHF). The Fibrosis-4 (FIB4) index, a non-invasive and easily calculated marker, has been used for hepatic diseases and reflects adverse prognosis. It is not clearly established whether the FIB4 index at admission can predict adverse outcomes in patients with AHF.

Methods And Results: From a multicenter AHF registry, we retrospectively evaluated 1162 consecutive patients admitted due to AHF (median age 78 [69-85] years and 702 patients [60.4%] were male). The FIB4 index at admission was calculated as: age (yrs) × aspartate aminotransferase [U/L]/(platelets count [10/μL] × √alanine aminotransferase [U/L]. The median value of the FIB4 index at admission was 2.79. All-cause mortality and rehospitalization due to HF at 12 months were investigated as a composite endpoint and occurred in 142 (12.2%) patients and 232 (20%) patients, respectively. Kaplan-Meyer analysis shows a significant increase in the composite endpoint from the first to fourth quartile group of the FIB4 index values (log-rank, p < 0.001). Multivariate Cox regression model revealed the FIB4 index was an independent risk predictor for composite endpoint in patients with AHF (3 months: HR ratio 1.013 [95% Confidence interval (CI):1.001-1.025]; p = 0.03, 12 months: HR 1.015 [95% CI:1.005-1.025]; p = 0.003, respectively). However, neither aspartate aminotransferase, alanine aminotransferase, nor platelet count was found to be a significant predictor.

Conclusions: Hepatic dysfunction evaluated with the FIB4 index at admission is a predictor of the composite endpoint of all-cause mortality and rehospitalization in AHF patients.
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http://dx.doi.org/10.1016/j.ijcard.2020.09.056DOI Listing
February 2021

Association between splenic volume and pulsatility index in patients with left ventricular assist devices.

Int J Artif Organs 2021 Apr 12;44(4):282-287. Epub 2020 Sep 12.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

The spleen serves as a blood volume reservoir for systemic volume regulation in heart failure (HF) patients. Changes are seen in spleen size in advanced HF patients after left ventricular assist device (LVAD) implantation. The pulsatility index (PI) is an indicator of native heart contractility with hemodynamic changes in patients using LVAD. We hypothesized that the splenic volume was associated with the PI, reflecting the hemodynamics in advanced HF patients with LVADs. Herein, we investigated the relationship between splenic volume and PI in these patients. Forty-four patients with advanced HF underwent implantation of HeartMate II (Abbott, Chicago, IL, USA) as a bridge to heart transplantation at the Nagoya University Hospital between October 2013 and June 2019. The data of 27 patients (21 men, median age 46 years) were analyzed retrospectively. All patients underwent blood tests, echocardiography, right heart catheterization, and computed tomography (CT). Spleen size was measured via CT volumetry; the splenic volume (median: 190 mL) correlated with right arterial pressure ( = 0.431,  = 0.025) and pulmonary capillary wedge pressure ( = 0.384,  = 0.048). On multivariate linear regression analysis, the heart rate (β = -0.452,  = 0.003), pump power (β = -0.325,  = 0.023), and splenic volume (β = 0.299,  = 0.038) were independent determinants of PI. The splenic volume was associated with PI, reflecting the cardiac preload in advanced HF patients with LVADs. Thus, spleen measurement using CT may help estimate the systemic volume status and understand the hemodynamic conditions in LVAD patients.
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http://dx.doi.org/10.1177/0391398820957019DOI Listing
April 2021

Successful weaning from veno-arterial ECMO and Impella2.5 by veno-venous and arterial ECMO (v-ECPELLA) for a patient with acute myocardial infarction complicated by severe lung injury.

J Cardiol Cases 2020 Sep 27;22(3):103-106. Epub 2020 May 27.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

The Impella™ (Abiomed, Danvers, MA, USA) is a percutaneous left ventricular assist device and is concurrently used with veno-arterial extracorporeal membrane oxygenation (VA ECMO). However, concomitantly using these two devices makes identifying the mixed zone of two opposite blood flows difficult. We report the case of an 80-year-old man with ST-elevation myocardial infarction and cardiopulmonary arrest. Emergent coronary angiography showed 99% stenosis in the left main trunk. A drug-eluting stent was placed under support of VA ECMO and the Impella2.5 for cardiogenic shock. During this support, antegrade deoxygenated blood enhanced by the Impella was sent to the right radial artery. Inadequate oxygenated blood was delivered through the native lung, which was damaged by cardiopulmonary resuscitation. We decided to convert to veno-venous and arterial ECMO (V-VA ECMO) using additional venous cannulation as drainage. Returned oxygenated blood was sent to the inferior vena cava and femoral artery bilaterally for maintaining oxygenation in the pulmonary artery. In V-VA ECMO and the Impella (v-ECPELLA), we attempted weaning from VA ECMO by only clamping VA cannulation and switching to veno-venous ECMO. We restored the setting to VA ECMO after assessment of the systemic circulation. We successfully managed and weaned our patient from simultaneous use of VA ECMO and the Impella2.5 by using v-ECPELLA. Simultaneous use of the Impella and veno-arterial extracorporeal membrane oxygenation (VA ECMO) is sometimes required in cases with severe lung injury. However, using these two devices may increase unexpected perfusion of unoxygenated blood in the coronary and cerebral arts. Veno-venous and arterial ECMO with the Impella can reduce the risk of hypoxia because of returned oxygenated blood to the inferior vena cava. This method might be useful for maintaining and weaning from simultaneous use of VA ECMO and the Impella.>.
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http://dx.doi.org/10.1016/j.jccase.2020.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452330PMC
September 2020

Relative bradycardia as a clinical feature in patients with coronavirus disease 2019 (COVID-19): A report of two cases.

J Cardiol Cases 2020 Dec 25;22(6):260-264. Epub 2020 Jul 25.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

We treated two patients with COVID-19 pneumonia requiring mechanical ventilation. Case 1 was a 73-year-old Japanese man. Computed tomography (CT) revealed ground-glass opacities in both lungs. He had severe respiratory failure with a partial pressure of oxygen in arterial blood/fraction of inspiratory oxygen ratio (P/F ratio) of 203. Electrocardiogram showed a heart rate (HR) of 56 beats/min, slight ST depression in leads II, III, and aVF, and mild saddle-back type ST elevation in leads V1 and V2. High-sensitivity cardiac troponin T (cTnT) level was slightly elevated. Despite a high fever and hypoxemia, his HR remained within 50-70 beats/min. Case 2 was a 52-year-old Japanese woman. CT revealed ground-glass opacities in the lower left lung. Electrocardiogram showed a HR of only 81 beats/min, despite a body temperature of 39.2 °C, slight ST depression in leads V4, V5, V6, and a prominent U wave in multiple leads. She had an elevated cTnT and a P/F ratio of 165. Despite a high fever and hypoxemia, her HR remained within 50-70 beats/min. Both patients had a poor compensatory increase in their HR, despite their critical status. Relative bradycardia could be a cardiovascular complication and is an important clinical finding in patients with COVID-19. < We report two Japanese cases of COVID-19 pneumonia with relative bradycardia as a condition and no significant compensatory increase in heart rate despite high fever and severe hypoxemia. Relative bradycardia in COVID-19 might be associated with myocardial injury due to not only direct viral involvement but also systemic inflammation. We should carefully observe the occurrence of relative bradycardia because it could potentially be a clinical sign of COVID-19.>.
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http://dx.doi.org/10.1016/j.jccase.2020.07.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381903PMC
December 2020

Impella 5.0 for Cardiogenic Shock After Thrombectomy in a Patient With Intraventricular Thrombosis.

Can J Cardiol 2020 10 11;36(10):1690.e13-1690.e15. Epub 2020 Apr 11.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

A 43-year-old man was admitted to a referring hospital for cardiogenic shock caused by dilated cardiomyopathy. Intra-aortic balloon pump and percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO) were started initially; however, a thrombus was detected in the left ventricle. After transfer to our institution, we performed thrombectomy through minithoracotomy. Subsequently, an Impella 5.0 device was inserted via the left subclavian artery. His cardiac function gradually improved, and both VA-ECMO and the Impella 5.0 could be weaned off. He was discharged without any thromboembolic event. Impella insertion with thrombectomy was possible, minimally invasive, and effective for a patient with intraventricular thrombosis associated with VA-ECMO.
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http://dx.doi.org/10.1016/j.cjca.2020.04.005DOI Listing
October 2020

Associations between hemodynamic parameters at rest and exercise capacity in patients with implantable left ventricular assist devices.

Int J Artif Organs 2021 Mar 12;44(3):174-180. Epub 2020 Aug 12.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Background: Hemodynamic parameters at rest are known to correlate poorly with peak oxygen uptake (VO) in heart failure. However, we hypothesized that hemodynamic parameters at rest could predict exercise capacity in patients with left ventricular assist device (LVAD), because LVAD pump rotational speed does not respond during exercise. Therefore, we investigated the relationships between hemodynamic parameters at rest (measured with right heart catheterization) and exercise capacity (measured with cardiopulmonary exercise testing) in patients with implantable LVAD.

Methods: We performed a retrospective medical record review of patients who received implantable LVAD at our institution from November 2013 to December 2017.

Results: A total of 20 patients were enrolled in this study (15 males; mean age, 45.8 years; median duration of LVAD support, 356 days). The mean peak VO and cardiac index (CI) were 13.5 mL/kg/min and 2.6 L/min/m, respectively. CI and hemoglobin level were significantly associated with peak VO (CI: r = 0.632, p = 0.003; hemoglobin: r = 0.520, p = 0.019). In addition, pulmonary capillary wedge pressure, right atrial pressure, and right ventricular stroke work index were also significantly associated with peak VO. In multiple linear regression analysis, CI and hemoglobin level remained independent predictors of peak VO (CI: β = 0.559, p = 0.006; hemoglobin: β = 0.414, p = 0.049).

Conclusions: CI at rest and hemoglobin level are associated with poor exercise capacity in patients with LVAD.
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http://dx.doi.org/10.1177/0391398820949888DOI Listing
March 2021

Efficacy of Pulmonary Artery Pulsatility Index as a Measure of Right Ventricular Dysfunction in Stable Phase of Dilated Cardiomyopathy.

Circ J 2020 08 22;84(9):1536-1543. Epub 2020 Jul 22.

Department of Cardiology, Nagoya University Graduate School of Medicine.

Background: Right ventricular dysfunction (RVD) in the setting of left ventricular (LV) myocardial damage is a major cause of morbidity and mortality, and the pulmonary artery pulsatility index (PAPi) is a novel hemodynamic index shown to predict RVD in advanced heart failure. However, it is unknown whether PAPi can predict the long-term prognosis of dilated cardiomyopathy (DCM) even in the mild to moderate phase. This study aimed to assess the ability of PAPi to stratify DCM patients without severe symptoms.Methods and Results:Between April 2000 and March 2018, a total of 162 DCM patients with stable symptoms were evaluated, including PAPi, and followed up for a median of 4.91 years. The mean age was 50.9±12.6 years and the mean LV ejection fraction (EF) was 30.5±8.3%. When divided into 2 groups based on median value of PAPi (low, L-PAPi [<3.06] and high, H-PAPi [≥3.06]), even though there were no differences in B-type natriuretic peptide or pulmonary vascular resistance, the probability of cardiac event survival was significantly higher in the L-PAP than in the H-PAP group by Kaplan-Meier analysis (P=0.018). Furthermore, Cox's proportional hazard regression analysis revealed that PAPi was an independent predictor of cardiac events (hazard ratio: 0.782, P=0.010).

Conclusions: Even in patients identified with DCM in the mild to moderate phase, PAPi may help stratify DCM and predict cardiac events.
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http://dx.doi.org/10.1253/circj.CJ-20-0279DOI Listing
August 2020

Usefulness of Plasma Branched-Chain Amino Acid Analysis in Predicting Outcomes of Patients with Nonischemic Dilated Cardiomyopathy.

Int Heart J 2020 Jul 18;61(4):739-747. Epub 2020 Jul 18.

Department of Cardiology, Nagoya University Graduate School of Medicine.

The metabolism of branched-chain amino acids (BCAAs) is reported to change in heart failure (HF) and correlate with cardiac function. However, the effect of BCAAs on HF remains controversial. We investigate the prognostic value of the plasma BCAA level in nonischemic dilated cardiomyopathy (NIDCM).This study enrolled 39 NIDCM patients, who underwent plasma amino acid (AA) analysis. The ratio of BCAAs to total AAs was calculated. All patients were divided into two groups at the median of BCAA/total AA ratio; high BCAA/total AA group (≥ 0.15, n = 20) and low BCAA/total AA group (< 0.15, n = 19). A cardiac event was defined as a composite of cardiac death, hospitalization for worsening HF, and lethal arrhythmia.The mean age was 51.1 ± 12.3 years and left ventricular ejection fraction (LVEF) was 32.7 ± 10.1%. In the low BCAA/total AA group, the body mass index and the total cholesterol level were lower than in the high BCAA/total AA group. The BCAA/total AA ratio was positively correlated with LVEF (r = 0.35, P = 0.031) and negatively correlated with brain natriuretic peptide (r = -0.37, P = 0.020). The low BCAA/total AA group had a lower cardiac event-free rate (5-year: 100% versus 73%; P = 0.019). In univariate analysis, angiotensin converting enzyme inhibitor or angiotensin II receptor blocker (hazard ratio: 0.045, P = 0.0014), hemoglobin (hazard ratio: 0.49 per 1 g/dL, P = 0.0022), and BCAA/total AA ratio < 0.15 (hazard ratio: not available, P = 0.0066) were major predictors for cardiac events.The BCAA/total AA ratio might be a useful predictor for future cardiac events in patients with NIDCM.
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http://dx.doi.org/10.1536/ihj.20-010DOI Listing
July 2020
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