Combinational elastography prior to pericardiectomy to assess liver condition in patients with constrictive pericarditis.

A 68-year-old man was diagnosed with pericarditis associated with immunoglobulin G4-related disease and was administered prednisolone 2 years prior to presentation. During the process of tapering off from prednisolone 1 year later, edema of the lower legs and pleural effusion worsened. He gradually developed dyspnea on exertion, and laboratory examinations revealed elevated liver enzyme levels. Diuretics were administered; however, the symptoms did not resolve. Transthoracic echocardiography and cardiac catheterization revealed findings consistent with those of constrictive pericarditis. Pericardiectomy was considered and the perioperative risks due to possible recovery from liver dysfunction were discussed. Combinational elastography was subsequently performed. The results indicated the absence of liver fibrosis, suggesting that liver dysfunction was attributable to liver congestion; thus, the liver dysfunction was considered reversible. Subsequently, pericardiectomy was performed. Given that constrictive pericarditis can lead to liver dysfunction due to congestion, the perioperative risk is often controversial when considering surgical interventions. Learning objective: Combinational elastography may be useful in the preoperative evaluation of patients with cardiac diseases complicated by liver dysfunction to distinguish liver fibrosis, understand the pathogenesis of liver dysfunction, and determine subsequent treatment strategies.

Evaluation of thyroid congestion in patients with heart failure using shear wave elastography: An observational study.

Shear wave elastography (SWE) is a noninvasive method for measuring organ stiffness. Liver stiffness measured using SWE reflects hepatic congestion in patients with heart failure (HF). However, little is known about the use of SWE to assess other organ congestions. This study aimed to evaluate the utility of SWE for assessing not only the liver but also thyroid congestion in patients with HF. This prospective study included 21 patients with HF who have normal thyroid lobes (age: 77.0 ±â€…11.0, men: 14). Thyroid and liver stiffness were measured by SWE using the ARIETTA 850 ultrasonography system (Fujifilm Ltd., Tokyo, Japan). SWE of the thyroid was performed on B-mode ultrasonography; a target region was identified within a region of interest. SWE was performed in each lobe of the thyroid gland. Five measurements were taken at the same location and the averages were recorded for comparison. We investigated the relationship between SWE for evaluating thyroid stiffness and the clinical characteristics of patients with HF. SWE of the thyroid was significantly correlated with SWE of the liver (R = 0.768, P < .001), thyroid stimulation hormone (R = 0.570, P = .011), free thyroxine (R = 0.493, P = .032), estimated right atrial pressure (RAP; R = 0.468, P = .033), and composite congestion score (R = 0.441, P = .045). SWE may be useful for evaluating thyroid stiffness and assessing the degree of thyroid congestion. Thyroid congestion may reflect the elevation of RAP and cause thyroid dysfunction through organ congestion.

Prognostic role of apolipoproteins on long-term major adverse cardiac events after percutaneous coronary intervention.

BACKGROUND/PURPOSE: Apolipoprotein (apo) levels are associated with coronary risk. However, the relationship between apo levels after percutaneous coronary intervention (PCI) and long-term major adverse cardiac events (MACEs) remains unclear. We aimed to investigate the association between lipid levels, including apo, at follow-up, and long-term MACEs in patients undergoing PCI. METHODS/MATERIALS: In total, 241 patients who underwent PCI between January 2004 and August 2008 were included in this study. MACEs were defined as cardiac death, acute coronary syndrome, or coronary revascularization of new lesions. The primary endpoint was MACE, and the secondary endpoint was a composite of cardiac death and acute coronary syndrome. RESULTS: During a mean follow-up period of 2079 days, the following cardiovascular events occurred in 78 patients: cardiovascular death (n = 1), non-fatal acute myocardial infarctions (n = 10), and revascularizations of new lesions (n = 67). Multivariate cox's proportional hazards analysis showed that the apo B level was an independent risk factor for MACEs (hazard ratio 1.11, 95 % confidence interval 1.03-1.20; P = 0.009). In the Kaplan-Meier estimation for primary endpoints, significant differences were observed in the apo B level and apo B/apo A1 ratio (P = 0.04 and P = 0.004, respectively). However, there was no difference in the LDL-C level and LDL-C/HDL-C ratio. At the secondary endpoint, only the apo B/apo A1 ratio was a prognostic factor (P = 0.007). CONCLUSIONS: In the long-term cardiovascular events of patients undergoing PCI, the apo B level and apo B/apo A1 ratio were more valuable prognostic factors for cardiovascular events compared to the LDL-C level and LDL-C/HDL-C ratio.

Burr entrapment in a percutaneous coronary intervention during rotational atherectomy: An experience with 3195 cases.

OBJECTIVES: Burr entrapment is a potentially life-threatening complication of rotational atherectomy (RA). However, owing to its infrequency, there have been no major reports on burr entrapment. This study aimed to evaluate the incidence, treatment, and outcomes of burr entrapment. METHODS: This multicenter retrospective study analyzed patients who had undergone percutaneous coronary interventions (PCIs) and were treated by RA between May 2013 and March 2022. RESULTS: Of the 22 640 PCI procedures, RA was performed in 3195 patients (14.1%), among whom burr entrapment occurred in 22 patients (0.69%). The mean patient age was 78 ± 8.7 years; 64% were male, and 32% were on dialysis. The entrapped burr size was 1.7 ± 0.2 mm, and the burr/artery ratio was 0.6 ± 0.1. In 20 patients (91%), the burr was extracted by strong manual pullback. The other patients underwent balloon angioplasty at the site of the entrapped burr, which might have provided space for successful burr withdrawal. Major adverse cardiac events occurred in 23% of patients. Tamponade requiring pericardiocentesis occurred in two patients (9%). No patients required emergency surgery or suffered an in-hospital death. CONCLUSIONS: Burr entrapment occurred in 0.69% of patients who had undergone RA. Most burrs were extracted by a strong manual pullback. None required emergency surgery, and there were no in-hospital deaths. The results provide a treatment approach and prognosis for burr stuck in the use of RA.

Incidence of Mid-Term Prognostic Events in Patients With Acute Coronary Syndrome During the Late 2010s in 2 Tertiary Hospitals in a Rural Area of Japan　- A Temporal Comparison.

Background: Data on the incidence of mid-term prognostic events in patients who developed acute coronary syndrome (ACS) in the late 2010s are scarce. Methods and Results: We retrospectively included and collected data for 889 patients with ACS (ST-elevation myocardial infarction [STEMI]/non-ST-elevation ACS [NSTE-ACS]) discharged alive from 2 tertiary hospitals in Izumo City, in rural Japan, between August 2009 and July 2018. Patients were divided into 3 time groups (T1: August 2009-July 2012; T2: August 2012-July 2015; T3: August 2015-July 2018). The cumulative incidence of major adverse cardiovascular events (MACE; comprising all-cause death, recurrent ACS, and stroke), major bleeding, and heart failure hospitalization within 2 years of discharge was compared among the 3 groups. The incidence of freedom from MACE was significantly higher in the T3 group than in the T1 and T2 groups (93 [95% confidence interval {CI} 90-96%] vs. 86% [95% CI 83-90] and 89% [95% CI 90-96], respectively; P=0.03). There was a tendency for a higher incidence of STEMI among patients in T3 (P=0.057). The incidence of NSTE-ACS was comparable among the 3 groups (P=0.31), as was the incidence of major bleeding and hospitalization for heart failure. Conclusions: The incidence of mid-term MACE in patients who developed ACS during the late 2010 s (2015-2018) was lower than that in prior periods (2009-2015).

Successful Transcatheter Aortic Valve Replacement Approached Via a Simultaneously Implanted Y-graft Vascular Prosthesis.

Transcatheter aortic valve replacement (TAVR) is mainly performed using the transfemoral (TF) approach. If the TF approach is difficult, the transapical (TA) or transaortic (TAo) approach is used; however, the complication rate is higher in such cases. In this case, abdominal aortic aneurysm (AAA) replacement and TAVR via artificial vessels were performed simultaneously because of anatomical difficulties in stent graft implantation and TF-TAVR for severe aortic stenosis (AS) associated with AAA. Performing TAVR simultaneously with AAA replacement avoids TA- or TAo-TAVR and allows for postoperative management in the absence of AS. Additionally, there is no need to create a new access for TAVR using artificial vessels. Since the long-term results of AAA are better with open surgery than with endovascular aneurysm repair and the age of indication for TAVR is expected to decrease due to valve-in-valve and other factors, simultaneous surgical AAA replacement and TAVR using a Y-graft vascular prosthesis is an effective treatment option when TF-TAVR is difficult to perform.

Subacute stent thrombosis with spontaneously resolved secondary thrombi in paroxysmal nocturnal hemoglobinuria: a case report.

BACKGROUND: Stent thrombosis (ST) is a serious complication; however, a method to prevent ST in patients with thrombophilic diseases has not been established. CASE PRESENTATION: We report a case of subacute ST in a patient with paroxysmal nocturnal hemoglobinuria (PNH) who was receiving continuous heparin treatment in addition to the usual dual antiplatelet therapy for contrast defects at the proximal site of the occluded right coronary artery and the proximal site of the left circumflex artery. Despite the resolution of thrombi in secondary lesions, subacute ST occurred. After percutaneous coronary intervention for ST, triple therapy, including oral anticoagulation for PNH-related thrombosis, was initiated. The patient subsequently underwent craniotomy hematoma removal for hemorrhagic cerebral infarction. CONCLUSIONS: Reported cases of ST in patients with PNH are very few, and this case adds evidence with respect to antithrombotic therapy in patients with thrombotic tendencies. Both thrombosis and bleeding should be considered when administering antithrombotic therapy to patients with thrombotic diseases. If there are specific treatments for thrombophilic diseases, they should be initiated early.

Gallbladder Wall Thickness-Based Assessment of Organ Congestion in Patients With Heart Failure.

Background: Diffuse gallbladder (GB) wall thickening is caused by elevated systemic venous pressure, such as heart failure (HF). This study investigated the relationship between GB wall thickness (WT) and HF, and the prognostic impact of GBWT. Methods and Results: This prospective study included 116 patients with HF and 11 healthy controls. Among the 116 patients, 30 with GBWT measurements in the postprandial state or a history and/or signs of GB disease were excluded. The remaining 86 patients had significantly higher GBWT than the controls (median [interquartile range {IQR}] 2.0 [1.7-2.4] vs. 1.3 [1.1-1.6] mm, respectively; P<0.001). GBWT was significantly correlated with B-type natriuretic peptide (r=0.386, P<0.001), left atrial volume index (r=0.452, P<0.001), and tricuspid annular plane systolic excursion (r=-0.311, P=0.006). GBWT also exhibited a stepwise increasing relationship with increasing HF stage (Stage B, 22 patients, median [IQR] 1.8 [1.7-2.1] mm; Stage C, 60 patients, 2.0 [1.8-2.5] mm; and Stage D, 4 patients: 4.0 [3.5-4.5] mm). In Stage C or D HF patients, 11 hospitalizations for HF were observed over a median follow-up of 303 days (IQR 125-394 days). Furthermore, the rate of hospitalization events for HF was significantly higher in the high (≥3 mm) than low GBWT group (P=0.007). Conclusions: GBWT can be used to assess organ congestion in patients with HF.

Negative-Pressure Pulmonary Edema and Takotsubo Cardiomyopathy in the Older Adults.

Negative-pressure pulmonary edema (NPPE) is a non-cardiogenic pulmonary edema caused by a sudden drop in the intrathoracic pressure associated with upper airway obstruction. Takotsubo cardiomyopathy (TCM) can often be triggered by intense stress and is more common in older women. In this case report, we describe a case of NPPE associated with upper airway obstruction and TCM associated with stress by upper airway obstruction in an 85-year-old woman. When encountering pulmonary edema associated with upper airway obstruction in older adults, the possibility of NPPE and TCM complications should be considered.

Combinational Elastography.

Heart failure (HF) can cause liver congestion and stiffness. Elastography is used to noninvasively measure organ stiffness. Liver fibrosis (LF) is monitored by shear wave and strain elastography. However, shear wave velocity (Vs) on shear wave elastography varies under the influence of fibrosis and congestion, and the LF index by strain elastography reflects only LF progression. Little is known about the usefulness of these methods in HF patients. This prospective study evaluated combined shear wave and strain elastography (i.e., combinational elastography) for assessing liver congestion. A total of 51 patients with HF (33 outpatients and 18 inpatients) and 10 healthy participants were included. Further, the relationships between combinational elastography and clinical characteristics in 51 patients with HF and the effects of medical treatment on these relationships in 18 inpatients with HF were investigated. Vs was significantly higher in the HF group than in the control group (1.68 ± 0.47 versus 1.21 ± 0.16, P = 0.002). The LF index did not significantly differ (1.39 ± 0.40 versus 1.33 ± 0.15, P = 0.680). Vs decreased after treatment (from 2.01 ± 0.61 to 1.62 ± 0.49 m/seconds; P = 0.026), while the LF index did not change (from 1.21 ± 0.29 to 1.26 ± 0.27; P = 0.664). Brain natriuretic peptide level (r = 0.343; P = 0.003) and composite congestion scores (r = 0.455; P < 0.001) were correlated with Vs. Combinational elastography is useful for assessing liver congestion, differentiating between liver congestion and fibrosis, and assessing therapeutic effects in HF patients.

Very Late Stent Thrombosis after Discontinuation of Antiplatelet Agents during Anticoagulation Therapy in a Patient with Peri-stent Contrast Staining after Implantation of a Second-generation Drug-eluting Stent.

A 54-year-old man was admitted to our hospital due to intermittent chest pain. He had a history of acute myocardial infarction, and peri-stent contrast staining had been observed at the stent implantation site. The patient previously underwent anticoagulation therapy for left ventricular thrombus and antiplatelet therapy to prevent stent thrombosis. More than one year after implantation of a drug-eluting stent, antiplatelet drugs were discontinued, and anticoagulant alone was prescribed according to the guidelines, which resulted in very late stent thrombosis. The risks of both bleeding and thrombosis must be fully considered when deciding whether or not to discontinue antiplatelet therapy during anticoagulation therapy.

Hydroxyzine-induced Torsade de Pointes in a Patient with Complete Atrioventricular Block.

An 82-year-old woman was admitted to our hospital because of dyspnea and bradycardia during exertion. Electrocardiography revealed complete atrioventricular block. During pacemaker implantation, a small dose (12.5 mg) of hydroxyzine was injected for sedation, and torsade de pointes (Tdp) occurred. The QT interval was prolonged after administration of hydroxyzine, and Tdp was observed after the R on T phenomenon occurred, indicating that hydroxyzine was capable of prolonging the QT interval and causing Tdp. Therefore, we must be cautious when administering hydroxyzine for sedation during surgery, especially in patients with bradycardia.