Publications by authors named "Yoshihiro J Akashi"

201 Publications

Correlation of Intravascular Ultrasound and Instantaneous Wave-Free Ratio in Patients With Intermediate Left Main Coronary Artery Disease.

Circ Cardiovasc Interv 2021 Jun 7:CIRCINTERVENTIONS120009830. Epub 2021 Jun 7.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.C.H., T.T., J.N., A.L.).

Background: There is great degree of interobserver variability in the visual angiographic assessment of left main coronary disease (LMCD). Fractional flow reserve and intravascular ultrasound are often used in this setting. The use of instantaneous wave-free ratio (iFR) for evaluation of LMCD has not been well studied. The aim of this study is to evaluate the use of iFR in the assessment of angiographically intermediate LMCD.

Methods: This is an international multicenter retrospective observational study of patients who underwent both iFR and intravascular ultrasound evaluation for angiographically intermediate LMCD. An independent core laboratory performed blinded off-line analysis of all intravascular ultrasound data. A minimum lumen area of 6 mm was used as the cutoff for significant disease.

Results: One hundred twenty-five patients (mean age, 68.4±9.5 years, 84.8% male) were included in this analysis. Receiver operating curve analysis showed that an iFR of ≤0.89 identified minimum lumen area <6 mm with an area under the curve of 0.77 (77% sensitivity, 66% specificity; <0.0001). Among the 69 patients without ostial left anterior descending artery or left circumflex artery disease, receiver operating curve analysis showed that an iFR of ≤0.89 identified minimum lumen area <6 mm with an area under the curve of 0.84 (70% sensitivity, 84% specificity; <0.0001). The correlation was not significantly different when the body surface area was considered.

Conclusions: In this study, in patients with intermediate LMCD, iFR of ≤0.89 correlates with intravascular ultrasound minimum lumen area <6 mm regardless of body surface area. The current study supports the use of iFR for the evaluation of intermediate LMCD.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.009830DOI Listing
June 2021

Post-COVID-19 Postural Orthostatic Tachycardia Syndrome.

Intern Med 2021 May 29. Epub 2021 May 29.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan.

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http://dx.doi.org/10.2169/internalmedicine.7626-21DOI Listing
May 2021

Myocardial Contractile Function Recovery, Systemic Inflammation, and Prognosis in Takotsubo Syndrome.

Circ J 2021 May 26. Epub 2021 May 26.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine.

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http://dx.doi.org/10.1253/circj.CJ-21-0322DOI Listing
May 2021

Weather temperature and the incidence of hospitalization for cardiovascular diseases in an aging society.

Sci Rep 2021 May 25;11(1):10863. Epub 2021 May 25.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.

Weather temperatures affect the incidence of cardiovascular diseases (CVD), but there is limited information on whether CVD hospitalizations are affected by changes in weather temperatures in a super-aging society. We aimed to examine the association of diurnal weather temperature changes with CVD hospitalizations. We included 1,067,171 consecutive patients who were admitted to acute-care hospitals in Japan between April 1, 2012 and March 31, 2015. The primary outcome was the number of CVD hospitalizations per day. The diurnal weather temperature range (DTR) was defined as the minimum weather temperature subtracted from the maximum weather temperature on the day before hospitalization. Multilevel mixed-effects linear regression models were used to estimate the association of DTR with cardiovascular hospitalizations after adjusting for weather, hospital, and patient demographics. An increased DTR was associated with a higher number of CVD hospitalizations (coefficient, 4.540 [4.310-4.765]/°C change, p < 0.001), with greater effects in those aged 75-89 (p < 0.001) and ≥ 90 years (p = 0.006) than among those aged ≤ 64 years; however, there were no sex-related differences (p = 0.166). Greater intraday weather temperature changes are associated with an increased number of CVD hospitalizations in the super-aging society of Japan, with a greater effect in older individuals.
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http://dx.doi.org/10.1038/s41598-021-90352-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149862PMC
May 2021

Influence of coronary artery disease and percutaneous coronary intervention on mid-term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation.

Clin Cardiol 2021 May 25. Epub 2021 May 25.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.

Background: A high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown.

Hypothesis: We hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI.

Methods: We divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non-LADp] group), and those without CAD (Non-CAD group). Clinical outcomes were compared among the three groups.

Results: The CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all-cause mortality than the other two groups (log-rank p = .001 and p = .008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all-cause mortality. However, PCI for an LM or LAD proximal lesion pre-TAVI did not reduce the risk of these outcomes.

Conclusions: CAD with an LM or LAD proximal lesion is a strong independent predictor of mid-term MACCEs and all-cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes.
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http://dx.doi.org/10.1002/clc.23655DOI Listing
May 2021

Association of PM exposure with hospitalization for cardiovascular disease in elderly individuals in Japan.

Sci Rep 2021 May 10;11(1):9897. Epub 2021 May 10.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.

Although exposure to particulate matter with aerodynamic diameters ≤ 2.5 µm (PM) influences cardiovascular disease (CVD), its association with CVD-related hospitalizations of super-aged patients in Japan remains uncertain. We investigated the relationship between short-term PM exposure and CVD-related hospitalizations, lengths of hospital stays, and medical expenses. We analyzed the Japanese national database of patients with CVD (835,405) admitted to acute-care hospitals between 2012 and 2014. Patients with planned hospitalizations and those with missing PM exposure data were excluded. We classified the included patients into five quintiles based on their PM exposure: PM-5, -4, -3, -2, and -1 groups, in descending order of concentration. Compared with the PM-1 group, the other groups had higher hospitalization rates. The PM-3, -4, and -5 groups exhibited increased hospitalization durations and medical expenses, compared with the PM-1 group. Interestingly, the hospitalization period was longer for the ≥ 90-year-old group than for the ≤ 64-year-old group, yet the medical expenses were lower for the former group. Short-term PM exposure is associated with increased CVD-related hospitalizations, hospitalization durations, and medical expenses. The effects of incident CVDs were more marked in elderly than in younger patients. National PM concentrations should be reduced and the public should be aware of the risks.
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http://dx.doi.org/10.1038/s41598-021-89290-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8110517PMC
May 2021

Prognostic significance of right ventricular function during exercise in asymptomatic/minimally symptomatic patients with nonobstructive hypertrophic cardiomyopathy.

Echocardiography 2021 May 10. Epub 2021 May 10.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.

Background: The risk stratification of hypertrophic cardiomyopathy (HCM) without left ventricular outflow tract (LVOT) obstruction and the utility of exercise stress echocardiography (ESE) remains unclear. We investigated the value of right ventricular (RV) function and RV-pulmonary artery (PA) coupling during exercise in asymptomatic/minimally symptomatic patients with nonobstructive HCM (nHCM).

Method And Results: This retrospective study evaluated 74 HCM patients (age 63 ± 13 years, 65% men) without LVOT obstruction (≥30 mmHg) who underwent​ ESE. Eight patients (11%) suffered from HCM-related cardiac events during a median 2.5 years follow-up. During exercise, tricuspid annular plane systolic excursion (Ex-TAPSE) and Ex-TAPSE/systolic pulmonary artery pressure [SPAP] ratio were more impaired in patients with than in those without events (22 ± 4 vs 26 ± 4 mm, P = .005; and 0.45 [0.41, 0.47] vs 0.56 [0.47, 0.82] mm/mmHg, P = .002). In Cox regression analysis, Ex-TAPSE (HR: 1.397, P = .002) and the Ex-TAPSE/SPAP ratio (HR: 2.737, P = .006) were associated with cardiac events. In Kaplan-Meier analysis, patients with a low Ex-TAPSE (<24 mm) and Ex-TAPSE/SPAP ratio (<0.50 mm/mmHg) had a higher incidence of adverse outcomes than those with high Ex-TAPSE (Log rank, P < .001 and =.001, respectively).

Conclusions: A low Ex-TAPSE and Ex-TAPSE/SPAP ratio were associated with adverse outcomes in nHCM. Evaluation of RV functional performance during exercise may play a crucial role in the risk stratification of nHCM.
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http://dx.doi.org/10.1111/echo.15075DOI Listing
May 2021

New Formula to Predict Heart Rate at Anaerobic Threshold That Considers the Effects of β-Blockers in Patients With Myocardial Infarction: MULTI-INSTITUTIONAL RETROSPECTIVE CROSS-SECTIONAL STUDY.

J Cardiopulm Rehabil Prev 2021 Apr 16. Epub 2021 Apr 16.

Department of Rehabilitation Medicine, St Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan (Drs Nemoto and Kasahara); Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan (Drs Nemoto, Kamiya, and Matsunaga); Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan (Dr Izawa); Department of Rehabilitation Medicine, St Marianna University School of Medicine Hospital, Kawasaki, Japan (Messrs Watanabe and Takeichi); Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan (Mr Yoshizawa); Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine Hospital, Kawasaki, Japan (Drs Suzuki and Akashi); Department of Internal Medicine, Shimazu Medical Clinic, Yokohama, Japan (Dr Omiya); and Department of Pharmacology, St Marianna University School of Medicine, Kawasaki, Japan (Dr Kida).

Purpose: It is recommended that patients with myocardial infarction (MI) be prescribed exercise by target heart rate (HR) at the anaerobic threshold (AT) via cardiopulmonary exercise testing (CPX). Although percent HR reserve using predicted HRmax (%HRRpred) is used to prescribe exercise if CPX or an exercise test cannot be performed, %HRRpred is especially difficult to use when patients take β-blockers. We devised a new formula to predict HR at AT (HRAT) that considers β-blocker effects in MI patients and validated its accuracy.

Methods: The new formula was created using the data of 196 MI patients in our hospital (derivation sample), and its accuracy was assessed using the data of 71 MI patients in other hospitals (validation sample). All patients underwent CPX 1 mo after MI onset, and resting HR, resting systolic blood pressure (SBP), and HRAT were measured during CPX.

Results: The results of multiple regression analysis in the derivation sample gave the following formula (R2 = 0.605, P < .001): predicted HRAT = 2.035 × (≥65 yr:-1, <65 yr:1) + 3.648 × (body mass index <18.5 kg/m2:-1, body mass index ≥18.5 kg/m2:1) + 4.284 × (β1-blocker(+):-1, β1-blocker(-):1) + 0.734 × (HRrest) + 0.078 × (SBPrest) + 36.812. This formula consists entirely of predictors that can be obtained at rest. HRAT and predicted HRAT with the new formula were not significantly different in the validation sample (mean absolute error: 5.5 ± 4.1 bpm).

Conclusions: The accuracy of the new formula appeared to be favorable. This new formula may be a practical method for exercise prescription in MI patients, regardless of their β-blocker treatment status, if CPX is unavailable.
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http://dx.doi.org/10.1097/HCR.0000000000000602DOI Listing
April 2021

Revisit to the Prognostic Value of Premature Atrial Contraction Burden in 24-h Holter Electrocardiography for Predicting Undiagnosed Atrial Fibrillation - A Propensity Score-Matched Study.

Circ J 2021 Apr 1. Epub 2021 Apr 1.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine.

Background: The optimum cut-off value of premature atrial contraction (PAC) burden (CV-PACb) in 24-h Holter electrocardiography (24-h ECG) for predicting atrial fibrillation (AF) is debatable, with few validation data.Methods and Results:We retrospectively analyzed 61 patients already diagnosed with AF (AD-AF) and 147 patients never diagnosed with AF (ND-AF), aged ≥50 years, free of heart disease, and who had undergone 24-h ECG and transthoracic echocardiography (TTE). Receiver operating characteristic analysis demonstrated that 0.4% was the optimal CV-PACb differentiating AD-AF from ND-AF, with 69% sensitivity and 72% specificity (area under the curve [AUC] 0.72; 95% confidence interval [CI] 0.65-0.79); however, the left atrial volume index was not significant (AUC 0.60; 95% CI 0.51-0.68). To verify the CV-PACb, new propensity-matched cohorts (i.e., subjects with a PAC burden ≥0.4% and <0.4%; n=69 in each group) were compared based on new detection of AF at a median follow-up of 50 months (interquartile range 12-60 months) Multivariable Cox regression analysis revealed that among 24-h ECG and TTE findings, only PAC burden ≥0.4% was independently associated with incident AF (hazard ratio 5.28; 95% CI 1.28-26.11; P=0.023).

Conclusions: A high PAC burden (≥0.4%) in 24-h ECG was a reliable indicator to identify undiagnosed AF, whereas TTE parameters did not show any predictive value.
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http://dx.doi.org/10.1253/circj.CJ-20-1277DOI Listing
April 2021

Plasma Concentration and Pharmacodynamics of Edoxaban in Patients with Nonvalvular Atrial Fibrillation and Acute Heart Failure.

Clin Pharmacokinet 2021 Mar 30. Epub 2021 Mar 30.

Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.

Objective: The objective of this study was to assess the pharmacokinetic and pharmacodynamic profiles and safety of edoxaban in patients with nonvalvular atrial fibrillation (NVAF) who were hospitalized with acute heart failure (AHF).

Methods: The trough plasma concentrations of edoxaban, and the coagulation biomarkers prothrombin fragments 1 and 2 (F1+2) and D-dimer, were determined. Twenty-six patients received edoxaban 60 mg (30 mg when dose adjustment was required) and blood samples were collected immediately before oral edoxaban administration for 7 consecutive days after hospitalization and on the day of discharge.

Results: The mean observation period was 13 (range 7-46) days. Trough plasma concentrations of edoxaban were constant from day 2 onwards. On day 1, the variation was greater owing to the differing intervals between the last edoxaban dose and day 1 blood collection. Trough plasma concentrations were higher in patients with reduced creatinine clearance (≤ 50 mL/min). Median values for F1+2 and D-dimer remained within normal ranges throughout the study. There were no drug discontinuations, and no serious adverse events were reported.

Conclusions: This is the first study of edoxaban pharmacokinetics and pharmacodynamics in patients with NVAF and AHF, and shows that the pharmacokinetic and pharmacodynamic profiles of edoxaban were constant during hospitalization. Thus, even in patients with NVAF and AHF, edoxaban anticoagulation therapy with guided dose adjustment is considered to be a safe and appropriate intervention. In particular, patients with reduced creatinine clearance should adhere to dose adjustment criteria.

Clinical Trial Registration: jRCTs031190006 (Japan Registry of Clinical Trials), 5 April, 2019 retrospectively registered.
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http://dx.doi.org/10.1007/s40262-021-00999-yDOI Listing
March 2021

Effect of Diastolic Flow Reversal Patterns on Clinical Outcomes Following Transcatheter Aortic Valve Implantation - An Intraprocedural Echocardiography Study.

Circ J 2021 Mar 24. Epub 2021 Mar 24.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine.

Background: Although diastolic flow reversal (DFR) in the descending aorta, assessed via transesophageal echocardiography (TEE), is a simple and easy indicator for evaluating aortic regurgitation, the association between DFR pattern and clinical outcomes following transcatheter aortic valve implantation (TAVI) is unclear. The purpose of this study was to evaluate the effect of DFR patterns on clinical outcomes following TAVI.Methods and Results:Two-hundred and eleven patients (mean age, 83.6±5.7 years; 69% female) who underwent TAVI were retrospectively assessed via intraprocedural TEE. DFR was evaluated using pulsed-wave Doppler in the descending aorta before and after TAVI. The primary endpoint was major adverse cardio-cerebrovascular events (MACCEs). Although only 7 patients (3.3%) had moderate or severe paravalvular leak, as assessed by color Doppler echocardiography, holo-DFR (HDFR) was observed in 33 patients (16.0%) after TAVI. MACCEs occurred in 40 patients during the median follow up of 282 days (interquartile range: 160-478 days). The estimated cumulative MACCE-free survival at 1 year was significantly lower in patients with HDFR than in those without HDFR. A Cox proportional hazards analysis revealed that HDFR after TAVI was independently associated with MACCEs.

Conclusions: HDFR was associated with an increased risk of MACCEs after TAVI. DFR evaluated by intraprocedural echocardiography could serve as a simple and easy method for predicting clinical outcomes.
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http://dx.doi.org/10.1253/circj.CJ-20-1173DOI Listing
March 2021

Gender Differences in the Circadian and Seasonal Variations in Patients with Takotsubo Syndrome: A Multicenter Registry at Eight University Hospitals in East Japan.

Intern Med 2021 Mar 22. Epub 2021 Mar 22.

Department of Cardiology, Kyorin University School of Medicine, Tokyo, Japan.

Objective The aim of this study was to clarify the circadian and seasonal variations in addition to identify sex-based differences in Japanese patients with Takotsubo syndrome (TTS). Methods The authors conducted a retrospective observational study to analyse the differences between the groups based on sex. Patients The patients were registered out of each institute registry of the acute coronary syndrome (ACS) which contains a total of 10,622 cases in eight academic hospitals in east Japan. Results Data for 344 consecutive TTS (73 male and 271 female) were extracted from each hospital registry. In-hospital mortality was higher in the male group than in the female group (18% vs 7%; p=0.005). With regard to the circadian variations in all study patients, TTS events occurred most often in the afternoon and least often during the night. Moreover, the patterns of circadian variations in the female and male groups were the same as that of all study patients. TTS events occurred most frequently in the autumn and least often in the spring in the whole study cohort. Moreover, the seasonal variation in the female group showed the same pattern as that of the whole cohort. However, there were no significant seasonal differences in the incidence of TTS in the male group. Conclusion In a multicenter study in Japan, seasonal variation was observed in the female group but not in the male group. Circadian variation was observed in both groups. These results suggested that the pathogenesis and clinical features of TTS might therefore differ according to sex.
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http://dx.doi.org/10.2169/internalmedicine.6910-20DOI Listing
March 2021

Rationale and Design of Therapeutic Angiogenesis by Cell Transplantation Using Adipose-Derived Regenerative Cells in Patients With Critical Limb Ischemia - TACT-ADRC Multicenter Trial.

Circ Rep 2020 Aug 8;2(9):531-535. Epub 2020 Aug 8.

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

Despite the growing knowledge regarding optimal treatments for critical limb ischemia (CLI), there are still a considerable number of patients who have to undergo major limb amputation. Intramuscular injection of autologous adipose-derived regenerative cells (ADRCs) in these patients has shown therapeutic potential in improving tissue ischemia, in both preclinical and initial pilot studies. Here, we present a clinical protocol for ADRCs use in a multicenter trial. The TACT-ADRC multicenter trial is a prospective, interventional, single-arm, open-labeled study at 8 hospitals in Japan, investigating the safety and feasibility of intramuscular injections of ADRCs and testing the hypothesis that this treatment promotes neovascularization and improves major amputation-free survival rates in patients with CLI who have no other treatment option. 40 patients with CLI will be enrolled and followed up from November 2015 to November 2020. Freshly isolated autologous ADRCs will be injected into the target ischemic limbs. Survival rate, adverse events, major limb amputation, ulcer size, 6-min walking distance, numerical rating scale, ankle-brachial pressure index, skin perfusion pressure and digital subtraction angiography will be evaluated at baseline and during 6 months' follow-up. This trial will demonstrate whether implantation of autologous ADRCs is a safe and effective method for therapeutic angiogenesis, resulting in an improvement in major amputation-free survival rates in patients with CLI.
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http://dx.doi.org/10.1253/circrep.CR-20-0055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819646PMC
August 2020

The efficiency of exercise stress echocardiography for evaluating symptomatic mitral regurgitation.

Eur Heart J Case Rep 2021 Feb 8;5(2):ytab006. Epub 2021 Feb 8.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-city, Kanagawa, Japan.

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http://dx.doi.org/10.1093/ehjcr/ytab006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898570PMC
February 2021

Polymorphic Ventricular Tachycardia with QT Interval Prolongation Due to a Brain Tumor.

Intern Med 2021 Mar 1. Epub 2021 Mar 1.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan.

We herein report the case of a 20-year-old man with a history of epilepsy who presented with frequent transient loss of consciousness (T-LOC) and polymorphic ventricular tachycardia (VT) with QT interval prolongation. Blood investigations revealed panhypopituitarism. Following a biopsy, he was diagnosed with brain germinoma. During the biopsy, he had an episode of polymorphous VT with QT prolongation. There was no recurrence of T-LOC following chemotherapy and hormone replacement therapy. This case indicates the importance of checking the QT interval in patients with T-LOC, including those with seizures and brain tumors, to ensure appropriate treatment.
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http://dx.doi.org/10.2169/internalmedicine.6635-20DOI Listing
March 2021

A Novel 3-Dimensional Echocardiographic Transillumination Rendering With Transparency in the Evaluation of Paravalvular Leak After Transcatheter Aortic Valve Implantation.

Circ J 2021 Feb 29;85(3):317. Epub 2021 Jan 29.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine.

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http://dx.doi.org/10.1253/circj.CJ-20-1183DOI Listing
February 2021

Impact of perioperative change in physical function on midterm outcomes after transcatheter aortic valve implantation.

Heart Vessels 2021 Jul 23;36(7):1072-1079. Epub 2021 Jan 23.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.

Preoperative frailty diminishes the potential for functional recovery after transcatheter aortic valve implantation (TAVI). However, perioperative changes in physical status and their impact on prognosis after TAVI have not previously been reported. Therefore, this study aimed to investigate whether perioperative changes in physical function affect prognosis in patients undergoing TAVI. We retrospectively reviewed 257 patients who underwent TAVI. The Short Physical Performance Battery (SPPB), an objective physical status assessment tool, was evaluated pre- and post-TAVI. Patients were divided into two groups: (i) patients whose SPPB score declined in the perioperative period (the decline group) and (ii) patients whose SPPB score did not decline in the perioperative period (the non-decline group). The primary endpoint was unplanned hospitalization owing to heart failure or cardiovascular death following TAVI. The mean follow-up period was 385 ± 151 days, mean age was 83.2 ± 5.8 years, and 67% of the patients were women. Sixteen patients required readmission owing to heart failure, and seven experienced cardiovascular-related death. Kaplan-Meier analysis revealed that the event-free rate was significantly lower in the decline group (log-rank, p = 0.006). A stepwise multivariate logistic regression analysis showed that a perioperative change in SPPB was significantly associated with primary endpoints (odds ratio, 1.51; 95% confidence interval, 1.12-2.04). Perioperative change in physical function was an independent risk factor for heart failure, hospitalization, or cardiovascular death following TAVI.
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http://dx.doi.org/10.1007/s00380-021-01776-4DOI Listing
July 2021

McConnell's sign assessed by point-of-care cardiac ultrasound associated with in-hospital mortality of COVID-19 patients with respiratory failure.

J Echocardiogr 2021 03 16;19(1):67-69. Epub 2021 Jan 16.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.

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http://dx.doi.org/10.1007/s12574-020-00507-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811147PMC
March 2021

Association between acute myocardial infarction-to-cardiac rupture time and in-hospital mortality risk: a retrospective analysis of multicenter registry data from the Cardiovascular Research Consortium-8 Universities (CIRC-8U).

Heart Vessels 2021 Jun 16;36(6):782-789. Epub 2021 Jan 16.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-City, Kanagawa, 216-8511, Japan.

Despite the known association of cardiac rupture with acute myocardial infarction (AMI), it is still unclear whether the clinical characteristics are associated with the risk of in-hospital mortality in patients with AMI complicated by cardiac rupture. The purpose of this study was to investigate the association between the time of cardiac rupture occurrence and the risk of in-hospital mortality after AMI. We conducted a retrospective analysis of multicenter registry data from eight medical universities in Eastern Japan. From 10,278 consecutive patients with AMI, we included 183 patients who had cardiac rupture after AMI, and examined the incidence of in-hospital deaths during a median follow-up of 26 days. Patients were stratified into three groups according to the AMI-to-cardiac rupture time, namely the > 24-h group (n = 111), 24-48-h group (n = 20), and < 48-h group (n = 52). Cox proportional hazards regression analysis was used to estimate the hazard ratio (HR) and the confidence interval (CI) for in-hospital mortality. Around 87 (48%) patients experienced in-hospital death and 126 (67%) underwent a cardiac surgery. Multivariable Cox regression analysis revealed a non-linear association across the three groups for mortality (HR [CI]; < 24 h: 1.0, reference; 24-48 h: 0.73 [0.27-1.86]; > 48 h: 2.25 [1.22-4.15]) after adjustments for age, sex, Killip classification, percutaneous coronary intervention, blood pressure, creatinine, peak creatine kinase myocardial band fraction, left ventricular ejection fraction, and type of rupture. Cardiac surgery was independently associated with a reduction in the HR of mortality (HR [CI]: 0.27 [0.12-0.61]) and attenuated the association between the three AMI-to-cardiac rupture time categories and mortality (statistically non-significant) in the Cox model. These data suggest that the AMI-to-cardiac rupture time contributes significantly to the risk of in-hospital mortality; however, rapid diagnosis and prompt surgical interventions are crucial for improving outcomes in patients with cardiac rupture after AMI.
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http://dx.doi.org/10.1007/s00380-020-01762-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093173PMC
June 2021

Z-shape phenomenon of optical coherence tomography catheter: potential cause of coronary perforation.

Eur Heart J Case Rep 2020 Aug 25;4(4):1-2. Epub 2020 Jul 25.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa 216-8511, Japan.

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http://dx.doi.org/10.1093/ehjcr/ytaa216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7780488PMC
August 2020

Successful exclusion of coronary artery aneurysm by utilizing shortening of covered stent to avoid side-branch occlusion.

Cardiovasc Interv Ther 2021 Jan 2. Epub 2021 Jan 2.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.

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http://dx.doi.org/10.1007/s12928-020-00740-9DOI Listing
January 2021

Pulmonary Artery Occlusion Due to Abrupt Pinhole Rupture of Aortic Arch Aneurysm.

JACC Cardiovasc Interv 2021 01 23;14(2):e15-e16. Epub 2020 Dec 23.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.

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http://dx.doi.org/10.1016/j.jcin.2020.11.028DOI Listing
January 2021

Concurrent onset of acute lupus myocarditis, pulmonary arterial hypertension and digital gangrene in a lupus patient: a possible role of vasculitis to the rare disorders.

Mod Rheumatol Case Rep 2020 01 13;4(1):21-27. Epub 2019 Aug 13.

Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.

Acute lupus myocarditis and pulmonary arterial hypertension (PAH) are rare complications associated with systemic lupus erythematosus (SLE). No previous reports have shown the coexistence of these disorders. Here we present a 41-year-old patient with SLE who concurrently developed severe acute lupus myocarditis and PAH with digital gangrene as an initial manifestation. Acute lupus myocarditis and PAH were successfully treated with prednisolone and intravenous cyclophosphamide pulse therapy (600-700 mg × 6) along with anticoagulant therapy. Catheter-directed thrombolysis was required for digital gangrene caused by vasculitis. Concurrent development of these rare disorders may represent a common mechanism such vasculitis as an underlining cause of SLE.
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http://dx.doi.org/10.1080/24725625.2019.1650698DOI Listing
January 2020

Effect of Immunosuppressive Therapy on Clinical Outcomes for Patients With Aortic Stenosis Following Transcatheter Aortic Valve Implantation.

Circ J 2020 11 13;84(12):2296-2301. Epub 2020 Oct 13.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine.

Background: Transcatheter aortic valve implantation (TAVI) is an established treatment for symptomatic patients with severe aortic stenosis (AS). Sometimes patients with severe AS taking immunosuppressants are encountered. The effect of immunosuppressive therapy on clinical outcomes in patients with AS following TAVI were investigated.Methods and Results:In total, 282 consecutive patients with severe AS who underwent transfemoral TAVI from January 2016 to December 2018 at St. Marianna University School of Medicine were reviewed. They were divided into 2 groups: the immunosuppressants group (IM group) in which patients continually used immunosuppressive drugs (n=22) and the non-immunosuppressants group (non-IM group) (n=260). The composite endpoints of a major adverse cardiovascular and cerebrovascular event (MACCE) defined as non-lethal myocardial infarction, unstable angina pectoris, heart failure requiring hospitalization, stroke, and cardiovascular death were evaluated. There were no differences in the incidence of vascular access complications (32% vs. 20%, P=0.143) and the rate of procedure success (100% vs. 93%, P=0.377) between the IM and non-IM groups. During the median follow-up period of 567 (16-1,312) days after the TAVI procedure, there were no significant differences between the IM and non-IM groups in the incidence of infectious complications (14% vs. 9%, P=0.442) or MACCE (18% vs. 20%, respectively; P=0.845).

Conclusions: The use of IM after TAVI is not associated with increased vascular access complications or mid-term MACCE in patients with severe AS treated with TAVI.
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http://dx.doi.org/10.1253/circj.CJ-20-0600DOI Listing
November 2020

Preventing thrombosis in a COVID-19 patient by combinatorial therapy with nafamostat and heparin during extracorporeal membrane oxygenation.

Acute Med Surg 2020 Oct 1. Epub 2020 Oct 1.

Division of Emergency Medicine and Critical Care Medicine St. Marianna University School of Medicine Japan.

Background: Extracorporeal membrane oxygenation (ECMO) can be life-saving in cases of coronavirus disease (COVID-19); however, circuit thrombosis is a complication. This report describes a COVID-19 patient treated with nafamostat and heparin to prevent circuit thrombosis during ECMO support.

Case Presentation: A 63-year-old man was transferred to our hospital with respiratory failure due to COVID-19 pneumonia. He was provided venous-venous ECMO to maintain oxygenation. During ECMO support, occlusive circuit thrombosis developed despite systemic anticoagulation therapy with heparin. He was subsequently administered combination therapy with nafamostat and heparin. Although the combination therapy could prevent circuit thrombosis, it was converted to heparin monotherapy because of hyperkalemia and hemothorax. After tracheostomy and a gradual improvement in oxygenation, ECMO was discontinued. He was transferred to another hospital for further rehabilitation.

Conclusion: Combination therapy with nafamostat and heparin can prevent circuit thrombosis during ECMO. However, bleeding can still develop with this combination therapy during ECMO.
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http://dx.doi.org/10.1002/ams2.585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537502PMC
October 2020

New-Generation Transcatheter Aortic Valves in Patients With Small Aortic Annuli - Comparison of Balloon- and Self-Expandable Valves in Asian Patients.

Circ J 2020 10 30;84(11):2015-2022. Epub 2020 Sep 30.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine.

Background: Asian patients have smaller aortic annuli. Although 20-mm balloon-expandable (BE) transcatheter heart valves (THV) are manufactured for transcatheter aortic valve implantation (TAVI) in these cases, the supra-annular design of self-expandable (SE) THV is considered more suitable; however, real-world comparative data are scarce.Methods and Results:Consecutive TAVI cases (n=330) in a single Japanese center were reviewed. Based on the cutoff for the new-generation 20-/23-mm BE-THV, a small aortic annulus was defined as <330 mm. A considerable number of patients had small annuli: 49/302 (16%). Of these, 33 BE-THV and 13 SE-THV using new-generation valves were compared. Although the SE-THV group had smaller annulus area (median 297 (interquartile range, 280-313) vs. 309 (303-323) mm(P=0.022)), it had more favorable post-procedural parameters; for SE-THV and BE-THV, respectively, effective orifice area (EOA), 1.5 (1.3-1.6) vs. 1.1 cm(0.9-1.3) (P=0.002); mean pressure gradient, 7.6 (5.6-11.0) vs. 14.2 mmHg (11.2-18.8) (P=0.001); and peak velocity, 1.8 (1.6-2.4) vs. 2.7 m/s (2.3-3.1) (P=0.001). Although new left bundle branch block was higher with SE-THV (24% and 62%, P=0.02), patient-prosthesis mismatch (PPM) ≥ moderate (indexed EOA <0.85 cm/m) was significantly less with SE-THV than with BE-THV (8% vs. 55%; P=0.04). Hemodynamic findings were consistent up to 1 year.

Conclusions: Small annuli are often seen in Asian patients, for whom SE-THV implantation results in favorable hemodynamics with less PPM.
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http://dx.doi.org/10.1253/circj.CJ-20-0368DOI Listing
October 2020

Comparison in Clinical Outcomes Between Leadless and Conventional Transvenous Pacemaker Following Transcatheter Aortic Valve Implantation.

J Invasive Cardiol 2020 Oct;32(10):400-404

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.

Objectives: Atrioventricular block is a common complication of transcatheter aortic valve implantation (TAVI). Although conventional transvenous dual-chamber (DDD) pacemaker (PM) is ideal for atrioventricular block, leadless PM, which is less invasive, may be suitable for frail TAVI patients. Little is known about clinical outcomes of this newer device following TAVI.

Methods: A total of 330 consecutive patients undergoing TAVI were reviewed. Of these, PM cases without atrial fibrillation were studied. Indication for leadless PM was based on heart team discussion.

Results: PM implantations were performed in 30 patients (9.1%), and 24 patients (7.3%) had no atrial fibrillation. These 24 patients had 14 DDD-PMs and 10 leadless PMs, and formed the two study groups. Baseline characteristics were similar except for ejection fraction: median ages were 83.0 years (IQR, 81.0-87.0 years) vs 86.5 years (IQR, 83.5-90.3) (P=.18); 11 (78.6%) vs 8 (80%) were women (P=.67); Society of Thoracic Surgeons scores were 5.1% (IQR, 3.8%-5.9%) vs 5.3% (IQR, 3.4%-8.5%) (P=.82); and ejection fractions were 68.0% (IQR, 66.0%-70.5%) vs 59.0% (IQR, 52.8%-69.3%) (P=.049), for the DDD-PM and leadless PM groups, respectively. There was 1 case of atrial lead dislodgment in the DDD-PM group; otherwise, no complications related to the implantation procedure were found. The leadless PM group showed numerically shorter hospital stay: 12.5 days (range, 9.0-17.8 day) in the DDD-PM group vs 10.5 days (range, 7.8-15.3 days) in the leadless PM group (P=.44). Six-month follow-up revealed no significant differences in incidence of heart failure rehospitalizations or deaths: 2 (14.3%) in the DDD-PM group vs 2 (25%) in the leadless PM group (P=.47); and 2 (14.3%) in the DDD-PM group vs 0 (0%) in the leadless PM group (P=.39), respectively.

Conclusions: Patients with leadless PM following TAVI may have shorter hospital stays, and clinical outcomes can be comparable with DDD-PMs. Leadless PMs may therefore be a reasonable option for frail TAVI patients.
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October 2020

A novel risk stratification system "Angiographic GRACE Score" for predicting in-hospital mortality of patients with acute myocardial infarction: Data from the K-ACTIVE Registry.

J Cardiol 2021 Feb 10;77(2):179-185. Epub 2020 Sep 10.

Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan.

Background: The Global Registry of Acute Coronary Events (GRACE) score is the most accurate risk assessment system for acute myocardial infarction (AMI), which was proposed in Western countries. However, it is unclear whether GRACE score is applicable to the present Japanese patients with a high prevalence of emergent percutaneous coronary intervention (PCI) and vasospasm. This study aimed to clarify the usefulness of GRACE risk score for risk stratification of Japanese AMI patients treated with early PCI and to evaluate a novel risk stratification system, "angiographic GRACE score," which is the GRACE risk score adjusted by the information of the culprit coronary artery and its flow at pre- and post-PCI, to improve its predicting availability.

Methods: The subjects were 1817 AMI patients who underwent PCI within 24 h of onset between October 2015 and August 2017 and were registered in Kanagawa Acute Cardiovascular (K-ACTIVE) Registry via survey form. The association between the clinical parameters and in-hospital mortality was investigated.

Results: A total of 79 (4.3%) in-hospital deaths were identified. The C-statistics for the in-hospital mortality of the GRACE score was 0.86, which was higher than that of the other conventional risk factors, including age (0.65), systolic blood pressure (0.70), heart rate (0.62), Killip classification (0.77), and serum levels of creatinine (0.68) and peak creatine kinase (0.74). The angiographic GRACE score improved the C-statistics from 0.86 of the original GRACE score to 0.89 (p < 0.05). In the setting of the cut-off value at 200, in-hospital mortality in the patients with the angiographic GRACE score <200 was 0.6%, which was relatively lower than those with ≥200, 9.4%.

Conclusions: The GRACE score is a useful predictor of in-hospital mortality among Japanese AMI patients in the PCI era. Moreover, the angiographic GRACE score could improve the predicting availability.
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http://dx.doi.org/10.1016/j.jjcc.2020.08.010DOI Listing
February 2021

Prognostic value of Mini Nutritional Assessment-Short Form with aortic valve stenosis following transcatheter aortic valve implantation.

ESC Heart Fail 2020 Sep 10. Epub 2020 Sep 10.

Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.

Aims: Older adults at risk for malnutrition are known to have a high mortality rate. This study aimed to investigate whether the Mini Nutritional Assessment-Short Form (MNA-SF) could predict midterm mortality in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods And Results: We applied the MNA-SF in 288 patients who had undergone TAVI from January 2016 to June 2019 at the St. Marianna University School of Medicine hospital. Using the MNA-SF cut-off value to indicate the risk of malnutrition, patients were divided into two groups, namely, those with an MNA-SF score ≤11 (impaired MNA-SF group) and those with an MNA-SF score ≥12 (maintained MNA-SF group). We used this value to investigate the association between the MNA-SF and all-cause mortality. Overall, 188 (65%) and 100 (35%) patients comprised the impaired MNA-SF and maintained MNA-SF groups, respectively, and 41 patients died after TAVI (mean follow-up duration, 458 ± 315 days). Kaplan-Meier analyses showed that patients in the impaired MNA-SF group had a significantly higher incidence of all-cause mortality (hazard ratio 2.67; 95% confidence interval 1.29-6.21; P = 0.01). Multivariate Cox regression analyses showed that the MNA-SF score was an independent predictor of all-cause mortality after adjusting for the Society of Thoracic Surgeons risk score, Katz Index, and brain natriuretic peptide test results (hazard ratio 1.14; 95% confidence interval 1.01-1.28; P = 0.04).

Conclusions: The MNA-SF was useful to screen for the risk of malnutrition in patients with TAVI and in predicting midterm prognoses in patients undergoing TAVI and could predict patient mortality after the procedure.
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http://dx.doi.org/10.1002/ehf2.13007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754760PMC
September 2020