Evaluation of Right Ventricular Function on Cardiac Magnetic Resonance Imaging and Correlation With Hemodynamics in Patients With Chronic Thromboembolic Pulmonary Hypertension.

Background: Balloon pulmonary angioplasty (BPA) is an alternative therapy for chronic thromboembolic pulmonary hypertension (CTEPH). Right heart catheterization (RHC) is essential to evaluate the efficacy of BPA. Cardiac magnetic resonance imaging (CMR) is also now used to assess the structure and function of the right heart non-invasively. The aim of this study was to correlate improvement in CMR with that on RHC, and compared with improvement in other non-invasive findings after BPA. Methods and Results: Forty-two patients underwent BPA between July 2012 and March 2015, and CMR, electrocardiography (ECG), and echocardiography were performed at the same time before and 6 months after BPA. Median pulmonary vascular resistance (PVR) was improved from 5.7 Wood units (IQR, 3.1-7.9 Wood units) to 2.7 Wood units (IQR, 1.6-3.9 Wood units; P<0.001). Changes in PVR were correlated with the changes in 5 CMR, 9 ECG, and 5 echocardiography parameters. On logistic analysis to identify the indicators of improving PH (i.e., PVR <3 Wood units), 4 CMR parameters were independently correlated with PVR change, one of which was median septal inversion ratio (SIR; 0.59; IQR, 0.54-0.63 to 0.54; IQR, 0.50-0.58, P<0.0001). SIR was the best predictor of PH (OR, 1.27; P<0.05). Conclusions: CMR can be used to estimate hemodynamic changes after BPA, and SIR is useful to predict alleviation of PH.

Patency of Saphenous Vein Grafts Using the PAS-Port System During Coronary Artery Bypass Surgery.

BACKGROUND: Several proximal anastomosis devices have been developed to shorten the time required for a proximal anastomosis and to avoid aortic cross-/side-clamping during coronary artery bypass grafting. This study retrospectively examined the patency of saphenous vein grafts (SVGs) using the PAS-Port System (Cardia Inc, Redwood City, CA). METHODS: From 2004 to 2014, 451 patients underwent coronary artery bypass graft operations requiring at least 1 proximal anastomosis using a PAS-Port device. A total of 802 PAS-Port devices were used, and 95.0% (762 of 802) were implanted successfully. Among the successfully implanted anastomoses, 76.8% (585 of 762) were evaluated using coronary angiography or multidimensional computed tomography, or both. The evaluations were performed between postoperative days 4 and 3,182 (mean, 319 ± 624 days). The early (1 to 365 days) and the midterm to long-term (more than 366 days) occlusion rates were examined. A complete postoperative clinical course was recorded for 70.7% of the patients. RESULTS: Overall, 93.8% (549 of 585) of the device-dependent SVGs were patent. The patency rates of device-dependent SVGs that were 1, 2, 3, 4, 5, 6, 7, and 8 years old were 90.1% ± 1.8%, 87.1% ± 2.3%, 86.1% ± 2.5%, 82.9% ± 3.3%, 80.6% ± 3.9%, 77.2% ± 5.0%, 77.2% ± 5.0%, and 70.2% ± 8.1%, respectively. The longest follow-up period was 3,182 days (8.7 years). The occlusion rate for device-dependent SVGs tended to decrease as the number of patients accumulated. CONCLUSIONS: The PAS-Port system provided acceptable SVG patency and clinical outcome for the early and midterm to long-term. There may be a learning curve for the use of PAS-Port device that affects the device-dependent SVG patency.

Clinical impact of non-culprit lesions on 1-year mortality in very elderly patients with acute coronary syndrome.

Preventive percutaneous coronary intervention (PCI) for non-culprit lesions after primary PCI remains controversial in patients with acute coronary syndrome (ACS). We analyzed whether PCI for non-culprit lesions would be associated with a better long-term prognosis in very elderly (≥85 years) patients. This study included 91 consecutive patients with ACS (mean age, 88.2 ± 3.0, 52 % male). We investigated the association of residual lesions with 1-year mortality. Culprit lesions affected the left anterior descending artery (LAD) in 50 patients, the left circumflex artery (LCx) in 29, and the right coronary artery (RCA) in 31. Residual lesions affected LAD in 20 cases, LCx in 22, and RCA in 21 patients. Residual lesions in LAD were associated with a higher 1-year mortality (p = 0.013), whereas residual lesions in LCx or RCA were not (p = 0.547 and 0.473, respectively). A Cox regression model demonstrated that patients with residual lesions in LAD had an increased risk of 1-year mortality compared with those without residual lesions (hazard ratio, 2.39; 95 % confidence interval, 1.16-4.96; p = 0.019). Therefore, the option to not treat residual lesions in LAD of patients with PCI may be associated with a higher 1-year mortality. Further studies are needed to confirm these findings.

Endovascular treatment for chronic pulmonary hypertension: a focus on angioplasty for chronic thromboembolic pulmonary hypertension.

INTRODUCTION: Percutaneous transluminal pulmonary angioplasty (PTPA) was introduced for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) in the late 20(th) century, and first attempts in collective patients were made in 2001 with beneficial effects but a moderate amount of complications. It was refined around 2010, and has been recently established as an effective and safe treatment. AREAS COVERED: The indication was originally inoperable CTEPH with peripheral lesions, but has now widened to symptomatic or hypoxic patients. The lesion is typically a meshwork-like structure of organized thrombi and is sometimes not seen as a stenosis angiographically, necessitating other means of investigation such as measurement of distal pressure. The technique to treat lesions is the same as for coronary angioplasty except in several ways. Expert commentary: The effects of PTPA are comparable to those of surgical endarterectomy, and the complications of reperfusion pulmonary edema and vascular injury are now controlled by several strategies and based on experience.

Barthel Index as a Predictor of 1-Year Mortality in Very Elderly Patients Who Underwent Percutaneous Coronary Intervention for Acute Coronary Syndrome: Better Activities of Daily Living, Longer Life.

BACKGROUND: Percutaneous coronary intervention (PCI) is safe and effective in very elderly patients, defined as those who are age ≥85 years, with acute coronary syndrome (ACS). However, the prognostic factors remain unknown. The association between activities of daily living (ADL) and the prognosis after PCI has not yet been investigated. HYPOTHESIS: Better ADL is associated with better 1-year prognosis. METHODS: This retrospective study included 91 consecutive very elderly patients with ACS. We calculated the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to BI: high BI (≥85) and low BI (<85). The BI was assessed both on admission (pre-BI) and at discharge (post-BI). RESULTS: In the 91 patients (mean age, 88.2 ± 3.0 years, 52% male), 1-year mortality was 33%. The Cox regression model demonstrated that low pre-BI was not a risk factor for 1-year mortality (hazard ratio: 0.73, 95% confidence interval [CI]: 0.30-1.78, P = 0.490). However, post-BI was significantly associated with 1-year mortality (hazard ratio: 0.25, 95% CI: 0.11-0.57, P = 0.001). The 1-year mortality of the high and the low post-BI group was estimated as 21% (95% CI: 12%-35%) and 62% (95% CI: 42%-82%), respectively. A 5-unit decrease in post-BI was related to a 1.10-fold increased risk for 1-year mortality (95% CI: 1.05-1.15, P < 0.001). CONCLUSIONS: Activities of daily living at discharge, although not before admission, may be a useful predictor for 1-year mortality in very elderly patients undergoing PCI for ACS.

Comparison of the reliability of E/E' to estimate pulmonary capillary wedge pressure in heart failure patients with preserved ejection fraction versus those with reduced ejection fraction.

Accurate assessment of pulmonary capillary wedge pressure (PCWP) is essential for physicians to effectively manage patients with acute decompensated heart failure. The ratio of early transmittal velocity to tissue Doppler mitral annular early diastolic velocity (E/E') is used to estimate PCWP noninvasively in a wide range of cardiac patients. However, it remains contentious as to whether mitral E/E' is a reliable predictor of PCWP. In the present study, acute heart failure patients were divided into two groups on the basis of left ventricular (LV) systolic function: those with preserved ejection fraction (HFpEF) and those with reduced ejection fraction (HFrEF). The usefulness of mitral E/E' in estimating PCWP was compared between the two groups. Fifty consecutive patients who were admitted with acute decompensated heart failure and underwent both right-sided cardiac catheterization and transthoracic echocardiography during hospitalization were analyzed retrospectively. Pearson's correlation was used to evaluate associations between Doppler parameters and PCWP. E/E' was positively correlated with PCWP (r = 0.56, P = 0.01) in the heart failure with preserved ejection fraction group. However, no significant relationship was observed between PCWP and mitral E/E' (P = 0.85) in the heart failure with reduced ejection fraction group. There were no significant correlations between any of the conventional parameters considered (LVEF, left atrial dimension, E/A, IVRT, and DT) with PCWP in either group. In conclusion, mitral E/E' is useful for estimating PCWP in patients with acute heart failure with preserved ejection fraction but may not in those with reduced ejection fraction.

Additional percutaneous transluminal pulmonary angioplasty for residual or recurrent pulmonary hypertension after pulmonary endarterectomy.

BACKGROUND: Pulmonary endarterectomy (PEA) has been the most effective therapy for chronic thromboembolic pulmonary hypertension (CTEPH). However, residual or recurrent pulmonary hypertension often persists after PEA. Recently, catheter-based angioplasty, called percutaneous transluminal pulmonary angioplasty (PTPA) or balloon pulmonary angioplasty, has been developed as a promising strategy for CTEPH. Therefore, the usefulness of PTPA for residual or recurrent pulmonary hypertension after PEA was investigated. METHODS: Thirty-nine patients underwent PEA from January 2000, and a total of 423 consecutive PTPA sessions in 110 patients were performed from January 2009 to May 2014. Of them, 9 patients (23.0% of 39 patients undergoing PEA and 8.2% of 110 patients undergoing PTPA) had undergone previous PEA and additional PTPA. RESULTS: In these 9 patients, pulmonary vascular resistance (PVR) was 15.6 (7.8-18.9) wood units at baseline, and significantly improved after PEA [5.6 (3.5-6.5) wood units] (p<0.05). However, PVR gradually deteriorated before PTPA [8.1 (6.1-12.3) wood units] compared to after PEA, suggesting that these 9 patients had residual or recurrent pulmonary hypertension after PEA. PTPA was performed at 4.1 (2.7-7.9) years after PEA. Follow-up catheterization at 1.9 (1.3-3.3) years after PTPA revealed significant improvement of PVR [4.2 (2.8-4.8) wood units] (p<0.05). CONCLUSIONS: A hybrid approach combining PEA and additional PTPA may be reasonable for patients with both proximal and very distal lesions not easily approachable by PEA. PTPA could be a promising alternative therapeutic strategy for residual or recurrent pulmonary hypertension after PEA.

Pressure-wire-guided percutaneous transluminal pulmonary angioplasty: a breakthrough in catheter-interventional therapy for chronic thromboembolic pulmonary hypertension.

OBJECTIVES: This study sought to prove the safety and effectiveness of pressure-wire-guided percutaneous transluminal pulmonary angioplasty (PTPA). BACKGROUND: PTPA has been demonstrated to be effective for treatment of chronic thromboembolic pulmonary hypertension. However, a major and occasionally fatal complication after PTPA is reperfusion pulmonary edema. To avoid this, we developed the PEPSI (Pulmonary Edema Predictive Scoring Index). The pressure wire has been used to detect insufficiency of flow in a vessel. METHODS: We included 350 consecutive PTPA sessions in 103 patients with chronic thromboembolic pulmonary hypertension from January 1, 2009 to December 31, 2013. During these 5 years, 140 PTPA sessions were performed without guidance, 65 with guidance of PEPSI alone, and 145 with both PEPSI and pressure-wire guidance. Each PTPA session was finished after achieving PEPSI scores of <35.4 with PEPSI guidance and each target lesion achieving distal mean pulmonary arterial pressure <35 mm Hg with pressure-wire guidance. RESULTS: The occurrence of clinically critical reperfusion pulmonary edema and vessel injuries were lowest in the group using the guidance of both pressure wire and PEPSI (0% and 6.9%, respectively). Furthermore, the group guided by pressure wire and PEPSI accomplished the same hemodynamic improvements with fewer numbers of target lesions treated and sessions performed. CONCLUSIONS: The combined approach using pressure wire and PEPSI produced more efficient clinical results and greatly reduced reperfusion pulmonary edema and vessel complications. This is further evidence that PTPA is an alternative strategy for treating chronic thromboembolic pulmonary hypertension.

Safety and efficacy of percutaneous transluminal pulmonary angioplasty in elderly patients.

BACKGROUND: Percutaneous transluminal pulmonary angioplasty (PTPA) is a recently developed catheter-based therapy for chronic thromboembolic pulmonary hypertension (CTEPH). The aim of the present study was to investigate the safety and efficacy of PTPA in elderly patients with CTEPH. METHODS: In all, 257 PTPA sessions in 70 patients (median age 63 years) were analyzed. Patients were divided into two groups according to age: (i) a younger group (<65 years; n=39); and (ii) an elderly group (≥65 years; n=31). RESULTS: Hemodynamic improvements were comparable between the younger and elderly groups (63.1% vs. 68.2% decrease in pulmonary vascular resistance, respectively; P>0.05). The median length of stay in the intensive care unit after each session (1.0 vs. 1.0 days) and in hospital per session (9.2 vs. 9.4 days) was similar between the two groups (P>0.05 for all). The prevalence of reperfusion pulmonary edema (23.4% vs. 26.3% across all sessions) and other complications, such as contrast dye-induced nephropathy (0% vs. 2.0%), infection (0% vs. 0%), and neurological complications (0% vs. 1.0%), was comparable in the younger vs. elderly groups (P>0.05 for all). One-year all-cause mortality was similar in the younger and elderly groups (0% vs. 3.2%, respectively; P>0.05). CONCLUSIONS: PTPA can be performed safely and effectively, even in elderly patients, and could be considered as an alternative therapeutic strategy for elderly patients who are too fragile for pulmonary endarterectomy (PEA) or who are treated in institutions without highly experienced PEA surgeons.

Pulmonary edema predictive scoring index (PEPSI), a new index to predict risk of reperfusion pulmonary edema and improvement of hemodynamics in percutaneous transluminal pulmonary angioplasty.

OBJECTIVES: This study sought to identify useful predictors for hemodynamic improvement and risk of reperfusion pulmonary edema (RPE), a major complication of this procedure. BACKGROUND: Percutaneous transluminal pulmonary angioplasty (PTPA) has been reported to be effective for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). PTPA has not been widespread because RPE has not been well predicted. METHODS: We included 140 consecutive procedures in 54 patients with CTEPH. The flow appearance of the target vessels was graded into 4 groups (Pulmonary Flow Grade), and we proposed PEPSI (Pulmonary Edema Predictive Scoring Index) = (sum total change of Pulmonary Flow Grade scores) × (baseline pulmonary vascular resistance). Correlations between occurrence of RPE and 11 variables, including hemodynamic parameters, number of target vessels, and PEPSI, were analyzed. RESULTS: Hemodynamic parameters significantly improved after median observation period of 6.4 months, and the sum total changes in Pulmonary Flow Grade scores were significantly correlated with the improvement in hemodynamics. Multivariate analysis revealed that PEPSI was the strongest factor correlated with the occurrence of RPE (p < 0.0001). Receiver-operating characteristic curve analysis demonstrated PEPSI to be a useful marker of the risk of RPE (cutoff value 35.4, negative predictive value 92.3%). CONCLUSIONS: Pulmonary Flow Grade score is useful in determining therapeutic efficacy, and PEPSI is highly supportive to reduce the risk of RPE after PTPA. Using these 2 indexes, PTPA could become a safe and common therapeutic strategy for CTEPH.

Percutaneous transluminal pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension.

BACKGROUND: Chronic thromboembolic pulmonary hypertension leads to pulmonary hypertension and right-sided heart failure. The purpose of this study was to investigate the efficacy of percutaneous transluminal pulmonary angioplasty (PTPA) for the treatment of chronic thromboembolic pulmonary hypertension. METHODS AND RESULTS: Twenty-nine patients with chronic thromboembolic pulmonary hypertension underwent PTPA. One patient had a wiring perforation as a complication of PTPA and died 2 days after the procedure. In the remaining 28 patients, PTPA did not produce immediate hemodynamic improvement at the time of the procedure. However, after follow-up (6.0 ± 6.9 months), New York Heart Association functional classifications and levels of plasma B-type natriuretic peptide significantly improved (both P<0.01). Hemodynamic parameters also significantly improved (mean pulmonary arterial pressure, 45.3 ± 9.8 versus 31.8 ± 10.0 mm Hg; cardiac output, 3.6 ± 1.2 versus 4.6 ± 1.7 L/min, baseline versus follow-up, respectively; both P<0.01). Twenty-seven of 51 procedures in total (53%), and 19 of 28 first procedures (68%), had reperfusion pulmonary edema as the chief complication. Patients with severe clinical signs and/or severe hemodynamics at baseline had a high risk of reperfusion pulmonary edema. CONCLUSIONS: PTPA improved subjective symptoms and objective variables, including pulmonary hemodynamics. PTPA may be a promising therapeutic strategy for the treatment of chronic thromboembolic pulmonary hypertension. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp. Unique identifier: UMIN000001572.

Left ventricular dysfunction due to diffuse multiple vessel coronary artery spasm can be concealed in dilated cardiomyopathy.

AIMS: Many patients with idiopathic dilated cardiomyopathy (DCM) have been diagnosed on the basis of the exclusion of significant coronary stenosis and the presence of left ventricular (LV) dysfunction. In the present study, we investigated the possibility that coronary multispasm is one of the mechanisms leading to diffuse idiopathic DCM-like LV dysfunction. METHODS AND RESULTS: Forty-two patients with severely depressed LV function but without significant coronary stenosis were enrolled (baseline LV ejection fraction, 33 ± 11%). An acetylcholine (ACh) provocation test was performed at the time of coronary angiography. In patients with a positive ACh provocation test (n = 20), coronary angiography revealed multivessel diffuse coronary spasm with marked electrocardiogram changes. In patients with a negative ACh provocation test (n = 22), significant findings compatible with idiopathic DCM were more frequently observed on magnetic resonance imaging (MRI) or in LV biopsies compared with the ACh-positive group (MRI, 73% vs. 12%; and LV biopsy, 71% vs. 0%, respectively; P < 0.01). In the ACh-positive group, LV function significantly improved after the administration of calcium channel blockers (LV ejection fraction, 34 ± 12% vs. 54 ± 10%; and brain natriuretic peptide, 803 ± 482 pg/mL vs. 69 ± 84 pg/mL, at baseline and 1 year, respectively; P < 0.01). CONCLUSIONS: Our results raise the possibility that patients with LV dysfunction due to repeated coronary multispasm are being diagnosed as idiopathic DCM, and that calcium channel blockers may prove to be a promising therapeutic strategy in those patients.

Heart rate turbulence can predict cardiac mortality following myocardial infarction in patients with diabetes mellitus.

BACKGROUND: Previous studies have described the clinical utility of heart rate turbulence (HRT) as an autonomic predictor in risk-stratifying patients after myocardial infarction (MI). Some reports showed that diabetes mellitus (DM) affects the prognostic value of autonomic markers. We assessed the utility of HRT as a risk marker in post-MI patients with DM and without DM. METHODS: We prospectively enrolled 231 consecutive DM patients and 300 non-DM patients after acute MI. HRT was measured using an algorithm based on 24-hour Holter electrocardiograms (ECGs), assessing 2 parameters: turbulence onset (TO) and turbulence slope (TS). HRT was considered positive when both TO ≥0% and TS ≤2.5 ms/R-R interval were met. The endpoint was defined as cardiac mortality. RESULTS: Of patients with DM, 9 patients (4%) were not utilized for HRT assessment because of frequent ventricular contractions or presence of atrial fibrillation. Forty-two of 222 patients (19%) were HRT positive. During follow-up of 876 ± 424 days, 26 patients (22%) reached the endpoint. Several factors including left ventricular ejection fraction (LVEF), renal dysfunction, documentation of nonsustained ventricular tachycardia (VT), and a HRT-positive outcome had significant association with the endpoint. Multivariate analysis determined that renal dysfunction and a positive HRT outcome had significant value with a hazard ratio (HR) of 4.7 (95%CI, 1.9-11.5; P = 0.0008) and 3.5 (95%CI, 1.4-8.8; P = 0.007), respectively. In non-DM patients, only a positive HRT outcome had significant value. CONCLUSIONS: This study reveals that HRT detected by 24-hour Holter ECG can predict cardiac mortality in post-MI patients whether DM is present or not.