Case report of belt electrode-skeletal muscle electrical stimulation for acute heart failure with severe obesity: a novel therapeutic option for acute phase rehabilitation

Background

Belt electrode skeletal muscle electrical stimulation (B-SES) is an emerging therapy anticipated to yield more favorable outcomes than conventional neuromuscular electrical stimulation (NMES), owing to its larger stimulation area. However, information on its efficacy and safety in patients with heart failure remains limited.

Case presentation

A 43-year-old man with a body mass index of 41 kg/m2 was admitted to our hospital for acute heart failure due to dilated cardiomyopathy. The patient required prolonged catecholamine support owing to poor cardiac function, and heart transplantation was considered. We initiated a mobilization program, but the patient's mobility was highly limited due to severe obesity and symptomatic orthostatic hypotension. B-SES was introduced to accomplish weight loss and early ambulation. We applied an intensive monitoring program for safe use and modulated the intensity of B-SES according to physical function. During the B-SES program, the patient's body weight decreased from 89.6 kg to 78.6 kg. Sequential evaluations of body composition and skeletal muscle ultrasonography revealed improved muscle mass, quality, and physical function. Furthermore, we explored the workload of B-SES using expiratory gas analysis. No adverse events were observed during B-SES.

Discussion

We successfully used B-SES to improve muscle function and morbidity in the treatment of acute heart failure. B-SES could be an option for patients with heart failure who have limited mobility and obesity.

Absence of Anaphylactic Reactions to Injection of Hemoglobin Vesicles (Artificial Red Cells) to Rodents

The safety and efficacy of hemoglobin vesicles (HbVs) as artificial oxygen carriers encapsulating a purified and concentrated Hb solution in liposomes have been studied extensively. The HbV surface, modified with PEG by incorporating a PEG-conjugated phospholipid, is beneficial for storage and biocompatibility. However, it might be possible that interaction of PEG and the pre-existing anti-PEG antibody in the bloodstream causes acute adverse reaction. This study used two sets of experiments with rats and guinea pigs to ascertain whether the anti-PEG antibody generated by the PEG-modified HbV injection can induce anaphylactic reactions. SD rats received repeated intravenous injection of HbV at a dose rate of 16 or 32 mL/kg three times. Not anti-PEG IgG but anti-PEG IgM was detected. Nevertheless, no anaphylactic reaction occurred. Guinea pigs were used to study the presence of active systemic anaphylaxis further after injections of the PEG-modified liposomes used for HbV. The animals were sensitized by three repeated subcutaneous injections of PEG-modified liposomes (PEG-liposome) along with adjuvant at 1 week intervals. For comparison, unmodified liposomes (liposome) and 10 times excessively PEG-modified liposomes with ionizable lipid (10PEG-DODAP-liposome) were used. Inclusion of PEG modification induced not only anti-PEG IgM but also anti-PEG IgG. Three weeks after the final injection, intravenous injection of both PEG-liposome and liposome (1 mL/kg) induced no anaphylactic reaction. However, the injection of 10PEG-DODAP-liposome showed one lethal anaphylaxis case and one mild anaphylaxis case. Antisera obtained from the animal sensitized as described above were inoculated (0.05 mL) intradermally into fresh guinea pigs. The presence of passive cutaneous anaphylaxis was evaluated after intravenous injections (1 mL/kg) of three liposomes with Evans blue. No dye leakage was detected at any inoculated skin point for PEG-liposome or liposome, but a slight leakage was detected in one inoculated skin point for 10PEG-DODAP-liposome. These results indicate the absence of acute allergic reactions at repeated injections of HbVs despite the anti-PEG antibody induction. Not all the PEG-modified liposomes show anaphylaxis, and it may depend on the amount of PEGylated phospholipid and lipid composition of PEG-modified liposomes.

Epidemiology of fragility fracture of the pelvic ring: a regional population-based study in Northern Japan

Using a regional population-based dataset in Japan, we identified the epidemiological characteristics of patients with fragility fractures of the pelvic ring. The incidence rate was 35.5-121.2 per 100,000 population/year. Age-specific incidence increased after 75 years. This fracture is associated with worse prognosis in terms of walking function and life expectancy.

PURPOSE

Fragility fracture of the pelvic ring (FFP) is common among older patients; however, little information is available on the epidemiology of FFP worldwide. We aimed to identify the epidemiological characteristics of patients with FFP using a regional population-based dataset in Japan.

METHODS

This descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with FFP from January 1, 2011 through December 31, 2020 at a regional dominant hospital in Japan. We calculated the crude and age-adjusted annual incidences and the age-specific incidence and described epidemiological date, injury characteristics, walking ability before and after FFP, and mortality. Additionally, we investigated factors associated with walking ability.

RESULTS

We identified 66 FFP patients, of whom 55 (83.3%) were female, with a mean age of 82.2 years. The crude annual incidence of FFP ranged from 35.5-121.2 per 100,000 population/year during the study period. The age-specific incidence of FFP increased after 75 and 80 years in females and males, respectively. In total, 44.4% of patients had declines in walking ability 1 year after their FFP injuries. Patients with declining walking ability were significantly older (p < 0.01), and age ≥ 80 years was significantly associated with the decline in walking ability (p < 0.01). The 1- and 5-year mortality rates were 15.4% and 39.9%, respectively.

CONCLUSION

The incidence rate of FFP was 35.5-121.2 per 100,000 population/year. Age-specific incidence of FFP increased after 75 years. Our results indicate that FFP is associated with worse prognosis of walking function and life expectancy.

Clinical valve thrombosis and arterial embolism in a cancer patient after transcatheter aortic valve replacement

The number of cancer patients with severe aortic stenosis and atrial fibrillation (AF) is increasing in the aging population. Transcatheter aortic valve replacement (TAVR) is an established treatment option for severe aortic stenosis with high surgical risk, including individuals with cancer. Antithrombotic therapy should be considered for post-TAVR or AF patients. However, antithrombotic management in cancer patients remains challenging due to the increased risk of both thromboembolism and bleeding. We present a case of clinical valve thrombosis and arterial embolism after transcatheter aortic valve replacement in an elderly patient with a history of metastatic pancreatic cancer and permanent atrial fibrillation under treatment of single antiplatelet therapy. Warfarin treatment after successful surgical thrombectomy to the occluded arteries improved clinical valve thrombosis, although the long-term outcome remains unclear. This case demonstrates that novel management algorithms for thromboembolism and bleeding in elderly cancer patients with AF and valvular heart disease are urgently needed.

Biomechanical comparisons of plate placement for medial tibial plateau fractures (Schatzker type IV): A biomechanical study using porcine tibias

INTRODUCTION

Biomechanical studies on medial tibial plateau fractures (MTPFs) (Schatzker classification type IV) are currently few, while studies using locking plates (LPs) placed on medial proximal tibias are unavailable. Hence, we compared the biomechanical properties of plate osteosynthesis at the medial and anteromedial placements using large- and small-fragment LPs in porcine bones.

MATERIALS AND METHODS

MTPFs were internally fixed using LPs on 40 porcine tibias. Specimens were equally divided into four groups: medial placement using a large-fragment LP (LPs for the medial (LM) group), anteromedial placement using a large-fragment LP (LAM group), medial placement using a small-fragment LP (SM group), and anteromedial placement using a small-fragment LP (SAM group). The translation patterns of the constructs in each group were examined by cycling loading test (displacement and translation along the mechanical axis at 10-100, 100-500, 500-1000, 1000-1500, and 1500-2000 cycles). Then, articular gaps and step-off changes after 2000 cycles were compared among the four groups.

RESULTS

One-way analysis of variance (ANOVA) revealed no significant differences in displacement and translation during cyclic loading. One-way ANOVA followed by post hoc analysis revealed that the anterior gap was lower in LPs for the medial (LM) than in SM (P = 0.029) and SAM (P = 0.0026). The central gap was also lower in LM than in SM (P = 0.042) and SAM (P < 0.001), and it was lower in LAM than in SAM (P = 0.047). Likewise, the posterior gap was lower in LM than in LAM (P = 0.025) and SAM (P < 0.001). Furthermore, the central step-off of SAM was higher than that of LM, LAM, and SM (P < 0.001, P = 0.0014, and P = 0.0077, respectively). The posterior step-off was lower in LM than in SAM and LAM (P = 0.037 and P < 0.001), and it was also lower in SM than in SAM (P = 0.0082).

CONCLUSION

Medial LP placement for MTPFs in porcine bones resulted in significantly lower posterior step-offs after cyclic loading than anteromedial placement, and large-fragment LPs for MTPFs caused significantly lower fracture gaps in the central articular after cyclic loading than small-fragment LPs.

Epidemiology of distal radius fracture: a regional population-based study in Japan

BACKGROUND

Distal radius fracture (DRF) is very common worldwide. In particular, aging countries have numerous patients with DRF, resulting in an urgent need for active preventive measures. As few epidemiological studies have investigated DRF in Japan, we aimed to identify the epidemiological characteristics of patients of all ages with DRF in Japan.

METHODS

This descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with DRF from January 1, 2011, to December 31, 2020, at a prefectural hospital in Hokkaido, Japan. We calculated the crude and age-adjusted annual incidences of DRF and described the age-specific incidence, injury characteristics (injury location and cause, seasonal differences, and fracture classification), and 1- and 5-year mortality rates.

RESULTS

A total of 258 patients with DRF were identified, of which 190 (73.6%) were female and the mean age (standard deviation) was 67.0 (21.5) years. The crude annual incidence of DRF ranged from 158.0 to 272.6 per 100,000 population/year, and the age-adjusted incidence among female patients demonstrated a significant decreasing trend during 2011-2020 (Poisson regression analysis; p = 0.043). The age-specific incidence differed by sex, with peaks at 10-14 years for males and 75-79 years for females. The most common cause of injury was a simple fall in patients > 15 year of age and sports injuries in patients ≤ 15 years of age. DRFs were most frequently sustained outdoors and were more common in the winter season. In patients > 15 years of age, the proportions of AO/OTA fracture types A, B, and C were 78.7% (184/234), 1.7% (4/234), and 19.6% (46/234), respectively, and 29.1% (68/234) of patients received surgical treatment for DRF. The 1- and 5-year mortality rates were 2.8% and 11.9%, respectively.

CONCLUSIONS

Our findings were mostly consistent with previous global studies. Although the crude annual incidence of DRF was relatively high because of recent population aging, the age-adjusted annual incidence among female patients showed a significant decreasing trend during this decade.

Potential value of saline-induced Pd/Pa ratio in patients with coronary artery stenosis

Background

Fractional flow reserve (FFR) is the current gold standard for identifying myocardial ischemia in individuals with coronary artery stenosis. However, FFR is not penetrated as much worldwide due to time consumption, costs associated with adenosine, FFR-related discomfort, and complications. Resting physiological indexes may be widely accepted alternatives to FFR, while the discrepancies with FFR were found in up to 20% of lesions. The saline-induced Pd/Pa ratio (SPR) is a new simplified option for evaluating coronary stenosis. However, the clinical implication of SPR remains unclear.

Objectives

In the present study, we aimed to compare the accuracies of SPR and resting full-cycle ratio (RFR) and to investigate the incremental value of SPR in clinical practice.

Methods

In this multicenter prospective study, 112 coronary lesions (105 patients) were evaluated by SPR, RFR, and FFR.

Results

The overall median age was 71 years, and 84.8% were men. SPR was correlated more strongly with FFR than with RFR (r = 0.874 vs. 0.713, respectively; p < 0.001). Using FFR < 0.80 as the reference standard variable, the area under the receiver-operating characteristic (ROC) curve for SPR was superior to that of RFR (0.932 vs. 0.840, respectively; p = 0.009).

Conclusion

Saline-induced Pd/Pa ratio predicted FFR more accurately than RFR. SPR could be an alternative method for evaluating coronary artery stenosis and further investigation including elucidation of the mechanism of SPR is needed (225 words).

Age prediction from coronary angiography using a deep neural network: Age as a potential label to extract prognosis-related imaging features

Coronary angiography (CAG) is still considered the reference standard for coronary artery assessment, especially in the treatment of acute coronary syndrome (ACS). Although aging causes changes in coronary arteries, the age-related imaging features on CAG and their prognostic relevance have not been fully characterized. We hypothesized that a deep neural network (DNN) model could be trained to estimate vascular age only using CAG and that this age prediction from CAG could show significant associations with clinical outcomes of ACS. A DNN was trained to estimate vascular age using ten separate frames from each of 5,923 CAG videos from 572 patients. It was then tested on 1,437 CAG videos from 144 patients. Subsequently, 298 ACS patients who underwent percutaneous coronary intervention (PCI) were analysed to assess whether predicted age by DNN was associated with clinical outcomes. Age predicted as a continuous variable showed mean absolute error of 4 years with R squared of 0.72 (r = 0.856). Among the ACS patients stratified by predicted age from CAG images before PCI, major adverse cardiovascular events (MACE) were more frequently observed in the older vascular age group than in the younger vascular age group (p = 0.017). Furthermore, after controlling for actual age, gender, peak creatine kinase, and history of heart failure, the older vascular age group independently suffered from more MACE (hazard ratio 2.14, 95% CI 1.07 to 4.29, p = 0.032). The vascular age estimated based on CAG imaging by DNN showed high predictive value. The age predicted from CAG images by DNN could have significant associations with clinical outcomes in patients with ACS.

Cost-Effectiveness of Dapagliflozin for Chronic Kidney Disease in Japan

BACKGROUND

The cost-effectiveness of sodium-glucose cotransporter 2 (SGLT2) inhibitors for chronic kidney disease (CKD) has not been evaluated in Japan, so we analyzed the cost-effectiveness of dapagliflozin, an SGLT2 inhibitor, for CKD stages 3a and 3b.Methods and Results: We used the Markov model for CKD to assess the costs and benefits associated with and without dapagliflozin from a health system perspective. We estimated the incremental cost-effectiveness ratio (ICER), expressed as per quality-adjusted life-years (QALYs). An ICER <5 million Japanese yen (JPY)/QALY was judged to be cost-effective. The effect of dapagliflozin on renal and cardiovascular events was based on published clinical trials. In patients with CKD stage 3a, the ICER of dapagliflozin over standard treatment was 4.03 million JPY/QALY gained. With a cost-effectiveness threshold of 5 million JPY/QALY gained, the cost-effectiveness probability of dapagliflozin over standard treatment was 52.6%. In patients with CKD stage 3b, the ICER of dapagliflozin over standard treatment was 0.12 million JPY/QALY gained. The cost-effectiveness probability of dapagliflozin over standard treatment was 75.2%.

CONCLUSIONS

The results seemed to show acceptable cost-effectiveness when dapagliflozin was used for CKD stage 3b. On the other hand, cost-effectiveness of dapagliflozin for CKD stage 3a was ambiguous, and further validation is needed.

Comparison of Two Types of Tapes for Taping After Breast Reconstruction Using Silicone Materials

Background:

Several kinds of tapes are used for postoperative wounds, which occasionally cause contact dermatitis and result in noticeable pigmentation. A comparison of the postoperative course between different tapes has not been reported. This study aimed at investigating the differences between two postoperative tapes used after breast reconstruction with silicone materials for simple mastectomy.

Materials and Methods:

Eighty-eight nonconsecutive patients undergoing tissue expander operation and 75 nonconsecutive patients undergoing tissue expander and silicone breast implant operations were included in this prospective study. Two postoperative tapes were used: a nonwoven surgical tape (Yu-ki ban^®) or a hypoallergenic polyester-woven fabric tape (Atofine _TM), which have different base materials, a removed keratinocyte area, and moisture permeability. We determined the differences in the incidence of skin complications, scar width, and aesthetic results with respect to scarring between the patients using Yu-ki ban and those using Atofine.

Results:

Statistically similar results were achieved for the patients who underwent reconstruction using either the tissue expander or silicone breast implant. Scar width was similar between the groups; however, the incidence of skin complications was significantly lower in patients using Atofine than in those using Yu-ki ban. Aesthetic results with respect to scarring were better in patients using Atofine than in those using Yu-ki ban, with a significant difference in the incidence of pigmentation between the groups.

Conclusion:

The tape with higher moisture permeability and a lower removed keratinocyte area should be used to reduce the incidence of contact dermatitis and achieve better aesthetic results with respect to scarring.

Agreement between single plane and biplane derived angiographic fractional flow reserve in patients with intermediate coronary artery stenosis

Fractional flow reserve (FFR) is often used to evaluate the physiological severity of intermediate coronary stenoses, but less-invasive assessment methods are desirable. We evaluated the feasibility of angiographic FFR (angioFFR) calculated from two projections acquired simultaneously by a biplane C-arm system and angioFFR calculated from two projections acquired independently by one plane of the same biplane C-arm system. AngioFFR was validated against FFR in terms of detection of hemodynamically relevant coronary artery stenoses. Twenty-two Patients who underwent angiography and FFR for coronary artery disease were included. We used a non-commercial prototype to calculate biplane angioFFR for 22 vessels (19 LAD, 1 LCx, 2 RCA) and single plane angioFFR for 17 of the same 22 vessels. FFR < 0.8 was measured in 8 vessels. The Pearson correlation coefficients with FFR were 0.55 for single plane angioFFR and 0.61 for biplane angioFFR and the diagnostic accuracies were 88% (95% CI 73-100%) for single plane angioFFR and 86% (95% CI 72-100%) for biplane angioFFR. Bland-Altman plots revealed that compared with FFR, the limits of agreement for single plane angioFFR were  - 0.07 to 0.19 (mean difference 0.06, p = 0.002) and the limits of agreement for biplane FFR were  - 0.09 to 0.15 (mean difference 0.03, p = 0.03). In conclusion, angioFFR calculated from single or biplane acquisitions by a biplane C-arm is feasible and may evolve to a tool for less invasive imaging-based assessment of myocardial ischemia.

Making the upper edge of a silicone breast implant invisible by fat onlay-grafting harvested from the affected inframammary fold

Background

In silicone breast implant (SBI)-based breast reconstructions, aesthetic outcomes are often low due to the visible upper edge of the SBI. To ameliorate this, grafting fat harvested from the SBI operative field has not been reported to date. Therefore, we aimed to develop a novel technique for fat onlay-grafting, harvested from the inframammary fold (IMF) of the reconstructed breast, and investigate its usefulness.

Methods

A total of 90 patients who underwent SBI-based breast reconstruction after a simple mastectomy were included in this study. The harvested fat was recorded by weight and grafted evenly to the medial and median upper edge of the SBI on the pectoralis major muscle. We applied this technique to 30 patients (fat onlay-grafting group) and compared them with the 60 patients (no-grafting group) who did not undergo our technique using the postoperative 1-year aesthetic outcome scores of the medial and median upper edge of the SBI. Furthermore, we investigated the correlation between the weight of harvested fat and body mass index.

Results

No postoperative wound complications occurred, and infection, hardened fat, and fat lysis were not found in the fat onlay-grafting group. The medial and total aesthetic outcome scores in the fat onlay-grafting group were significantly higher than those in the no-grafting group (P<0.05). The average weight of harvested fat was 11.9 [5-32] g. The correlation between the weight of the harvested fat and body mass index was significantly positive (R²=0.7119, P<0.05).

Conclusions

Our technique made the upper edge of the SBI invisible. Further, it was simple and less invasive with safe augmentation. Therefore, we believe that this technique can contribute to better aesthetic outcomes in SBI-based breast reconstruction.

Characteristics and in-hospital outcomes of patients undergoing balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a time-trend analysis from the Japanese nationwide registry

BACKGROUND

Balloon pulmonary angioplasty (BPA), a novel technique initially introduced as a treatment for inoperable chronic thromboembolic pulmonary hypertension, is now increasingly being performed in a broader spectrum of patients. Here, we performed a time-trend analysis of the characteristics and in-hospital outcomes of patients who underwent BPA in Japan, using data extracted from nationwide procedure-based registration system.

METHODS

The Japanese Structural Heart Disease (J-SHD) registry was established and sponsored by the Japanese Association of Cardiovascular Intervention and Therapeutics and aims to provide basic statistics on the performance of structural interventions in Japan. J-SHD registers cases from approximately 200 institutions, representing more than 90% of SHD intervention-performing hospitals in the nation. We analysed the registered BPA data elements from January 2015 to December 2018. Successful BPA was defined as a session in which a physician successfully treated all targeted lesions.

RESULTS

There were a total of 2512 BPA sessions; the number of institutions and registered sessions increased from 30 to 50 sites and from 479 to 852 sessions during the study period, respectively. The average age of the patients was 66±13 years, and 72.1% were women. In-hospital death was observed in 0.2%, and the total complications rate was 5.3%. The preoperative and postoperative mean pulmonary artery pressure were 32±11 mm Hg and 30±10 mm Hg, respectively.

CONCLUSION

The number of BPA sessions increased during the study period, with an acceptable in-hospital complication rate.

Automatic detection of vessel structure by deep learning using intravascular ultrasound images of the coronary arteries

Intravascular ultrasound (IVUS) is a diagnostic modality used during percutaneous coronary intervention. However, specialist skills are required to interpret IVUS images. To address this issue, we developed a new artificial intelligence (AI) program that categorizes vessel components, including calcification and stents, seen in IVUS images of complex lesions. When developing our AI using U-Net, IVUS images were taken from patients with angina pectoris and were manually segmented into the following categories: lumen area, medial plus plaque area, calcification, and stent. To evaluate our AI's performance, we calculated the classification accuracy of vessel components in IVUS images of vessels with clinically significantly narrowed lumina (< 4 mm2) and those with severe calcification. Additionally, we assessed the correlation between lumen areas in manually-labeled ground truth images and those in AI-predicted images, the mean intersection over union (IoU) of a test set, and the recall score for detecting stent struts in each IVUS image in which a stent was present in the test set. Among 3738 labeled images, 323 were randomly selected for use as a test set. The remaining 3415 images were used for training. The classification accuracies for vessels with significantly narrowed lumina and those with severe calcification were 0.97 and 0.98, respectively. Additionally, there was a significant correlation in the lumen area between the ground truth images and the predicted images (ρ = 0.97, R2 = 0.97, p < 0.001). However, the mean IoU of the test set was 0.66 and the recall score for detecting stent struts was 0.64. Our AI program accurately classified vessels requiring treatment and vessel components, except for stents in IVUS images of complex lesions. AI may be a powerful tool for assisting in the interpretation of IVUS imaging and could promote the popularization of IVUS-guided percutaneous coronary intervention in a clinical setting.

Deep Learning Algorithm to Detect Cardiac Sarcoidosis From Echocardiographic Movies

BACKGROUND

Because the early diagnosis of subclinical cardiac sarcoidosis (CS) remains difficult, we developed a deep learning algorithm to distinguish CS patients from healthy subjects using echocardiographic movies.Methods and Results:Among the patients who underwent echocardiography from January 2015 to December 2019, we chose 151 echocardiographic movies from 50 CS patients and 151 from 149 healthy subjects. We trained two 3D convolutional neural networks (3D-CNN) to identify CS patients using a dataset of 212 echocardiographic movies with and without a transfer learning method (Pretrained algorithm and Non-pretrained algorithm). On an independent set of 41 echocardiographic movies, the area under the receiver-operating characteristic curve (AUC) of the Pretrained algorithm was greater than that of Non-pretrained algorithm (0.842, 95% confidence interval (CI): 0.722-0.962 vs. 0.724, 95% CI: 0.566-0.882, P=0.253). The AUC from the interpretation of the same set of 41 echocardiographic movies by 5 cardiologists was not significantly different from that of the Pretrained algorithm (0.855, 95% CI: 0.735-0.975 vs. 0.842, 95% CI: 0.722-0.962, P=0.885). A sensitivity map demonstrated that the Pretrained algorithm focused on the area of the mitral valve.

CONCLUSIONS

A 3D-CNN with a transfer learning method may be a promising tool for detecting CS using an echocardiographic movie.

Factors associated with left ventricular reverse remodelling after percutaneous coronary intervention in patients with left ventricular systolic dysfunction

Percutaneous coronary intervention (PCI) is sometimes considered as an alternative therapeutic strategy to surgical revascularization in patients with coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF). However, the types or conditions of patients that receive the clinical benefit of left ventricular reverse remodelling (LVRR) remain unknown. The purpose of this study was to investigate the determinants of LVRR following PCI in CAD patients with reduced LVEF. From 4394 consecutive patients who underwent PCI, a total of 286 patients with reduced LV systolic function (LVEF < 50% at initial left ventriculography) were included in the analysis. LVRR was defined as LV end-systolic volume reduction ≥ 15% and improvement of LVEF ≥ 10% at 6 months follow-up left ventriculography. Patients were divided into LVRR (n = 63) and non-LVRR (n = 223) groups. Multivariate logistic regression analysis revealed that unprotected left main coronary artery (LMCA) intervention was significantly associated with LVRR (P = 0.007, odds ratios [OR] 4.70, 95% confidence interval [CI] 1.54-14.38), while prior PCI (P = 0.001, OR 0.35, 95% CI 0.19-0.66), presence of in-stent restenosis (P = 0.016, OR 0.32, 95% CI 0.12-0.81), and presence of de-novo stenosis (P = 0.038, OR 0.36, 95% CI 0.14-0.95) were negatively associated with LVRR. These data suggest the potential prognostic benefit of unprotected LMCA intervention for LVRR and importance of angiographic follow-up in patients with CAD and LV systolic dysfunction.

Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement for Aortic Stenosis in Japan - Analysis of a Nationwide Inpatient Database

Background: Nationwide data on transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in Japan are scarce. Methods and Results: Using a nationwide inpatient database, we analyzed patients undergoing TAVI (n=8,338) or SAVR (n=16,298) due to aortic stenosis between 2014 and 2017. The annual number of TAVI increased rapidly from 2014 to 2017, particularly in older patients. In-hospital deaths were lower and the length of hospital stay was shorter for patients undergoing TAVI than SAVR. Conclusions: TAVI has been penetrating in Japan as an alternative therapeutic option for aortic stenosis and is associated with acceptable clinical outcomes.

Efficacy of Fractional Flow Reserve-Guided Percutaneous Cornary Intervention for Patients with Angina Pectoris

Evaluation of hemodynamic parameters, such as fractional flow reserve (FFR), is recommended before percutaneous coronary intervention (PCI) for patients with angina pectoris (AP). However, the advantage of FFR-guided PCI has not been fully established. This study was performed to confirm whether FFR-guided PCI improves the prognosis compared with other treatments. Multiple databases were searched for studies published from 2000 to 2018, and a network meta-analysis (NMA) was performed to compare outcomes of FFR-guided PCI, non-FFR-guided PCI, coronary artery bypass grafting (CABG), and medical treatment (MT) for AP based on estimated odds ratios (ORs). The study included 18,093 patients from 15 randomized controlled trials (RCTs). No evidence of inconsistency was observed among the studies. The NMA showed that the all-cause mortality of FFR-guided PCI was not significantly different from that of the other treatment groups (CABG: OR, 1.1; 95% confidence interval [CI], 0.67-1.7; non-FFR-guided PCI: OR, 0.85; 95% CI, 0.53-1.4; and MT: OR, 0.83; 95% CI, 0.52-1.3). The NMA for the composite of all-cause mortality and myocardial infarction, which included 15,454 patients from 12 RCTs, showed that FFR-guided PCI significantly reduced the composite outcome compared with non-FFR-guided PCI and MT (non-FFR-guided PCI: OR, 0.66; 95% CI, 0.46-0.95 and MT: OR, 0.66; 95% CI, 0.46-0.95). Although FFR-guided PCI for AP did not show significant prognostic improvement compared with non-FFR-guided PCI, CABG, and MT, FFR-guided PCI may significantly reduce the composite of all-cause mortality and myocardial infarction compared with non-FFR-guided PCI and MT.

Efficacy of fractional flow reserve-guided percutaneous coronary intervention for patients with angina pectoris: a network meta-analysis

Background

Evaluation of hemodynamic parameters, such as fractional flow reserve (FFR), is recommended before percutaneous coronary intervention (PCI) for patients with angina pectoris (AP). However, the advantage of FFR-guided PCI has not been fully established. A network meta-analysis (NMA) synthesizes the results of studies on multiple competing interventions. Moreover, no NMA has evaluated randomized controlled trials for AP to compare FFR-guided PCI and other treatments. To clarify whether FFR-guided PCI improves the prognosis in patients with AP, we performed this study.

Methods

Multiple databases were searched for studies published from 2000 to 2018. The search terms were based on Medical Subject Headings and keywords including “angioplasty”, “coronary artery bypass”, “percutaneous coronary intervention”, “coronary disease”, and “randomized controlled trial”. And an NMA was performed to compare outcomes of FFR-guided PCI, non-FFR-guided PCI, coronary artery bypass grafting (CABG), and medical treatment (MT) for AP based on estimated odds ratios (ORs). The primary endpoint was all-cause mortality. The secondary endpoints were the occurrence of MI. Treatments were ranked by the surface under the cumulative ranking curve.

Results

The study included 18,093 patients from 15 randomized controlled trials. No evidence of inconsistency was observed among the studies. The NMA showed that the all-cause mortality of FFR-guided PCI was not significantly different from that of the other treatment groups (CABG: OR, 1.1; 95% confidence interval [CI], 0.67–1.7; non-FFR-guided PCI: OR, 0.85; 95% CI, 0.53–1.4; and MT: OR, 0.83; 95% CI, 0.52–1.3). The NMA for myocardial infarction, which included 13,548 patients from 11 randomized controlled trials, showed that FFR-guided PCI tended to reduce the occurrence of myocardial infarction compared with MT (OR, 0.60; 95% CI, 0.36–1.0). According to the surface under the cumulative ranking curve, CABG was the best treatment, followed by FFR-guided PCI, non-FFR-guided PCI, and MT.

Conclusions

FFR-guided PCI for AP showed no significant prognostic improvement compared with non-FFR-guided PCI, CABG, and MT. CABG was the best treatment for AP, followed by FFR-guided PCI, non-FFR-guided PCI, and MT.

Network plot and interval plot

Funding Acknowledgement

Type of funding source: None

Novel procedural method for balloon pulmonary angioplasty to treat chronic thromboembolic pulmonary hypertension

Background

The current strategy of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH) is to dilate branches as many as possible without lung injury to normalize mean pulmonary artery pressure and oxygenation. The shape of guiding catheter is one of the important factors to achieve this strategy. However, conventional guiding catheters which are typically used for BPA are difficult to introduce into particular branches. The Ikari-curve left (IL) guiding catheter may be suitable for this purpose by adjusting its curves (Figure 1); however, its utility and effectiveness for lung injury are unclear.

Purpose

The aim of this study is to clarify utility and safety of IL guiding catheter for BPA.

Methods

We retrospectively analyzed 202 consecutive BPA sessions of 40 patients with CTEPH from November 2016 to October 2019 and divided them into two groups; IL group, in which we used IL guiding catheter; and non-IL group in which we used others. IL guiding catheter was used for branches of left lung which are difficult to introduce by conventional catheter prior Nov. 2018. After Nov.2018, we also used it for the same type branches of right lung. The occurrence of lung injury was determined by the presence of bloody sputum during the perioperative period. We compared success rate of introduction into target vessels and of occurrence of lung injury.

Results

The average age of enrolled patients was 60.3±14.4 year-old and female was 65%. There were 99 sessions in IL group. The median treated branches significantly differed between groups (IL group: 15 vs. non-IL group: 10, p&lt;0.05). The lung injury rate tended to low in the IL group (4.0% vs. 11.7%, p=0.07). The IL group had more successful insertions into branches than did the non-IL group (right lung: middle lobe*, 84.4% vs. 57.5%; medial basal branch*, 46.9% vs. 7.5%; left lung: anterior ascending and descending branches, 82.9% vs. 70.8%; lingular branches*, 90.0% vs. 62.5%; anterior basal branch, 75.7% vs. 62.5%, * p&lt;0.05).

Conclusion

IL guiding catheter can be introduced into branches that cannot be accessed via conventional guiding catheters and has potential to reduce the occurrence of lung injury. 2228 characters including space

Figure1

Funding Acknowledgement

Type of funding source: None

Novel Balloon Pulmonary Angioplasty Technique for Chronic Thromboembolic Pulmonary Hypertension

This study aimed to clarify the usefulness of the Ikari-curve left (IL) guiding catheter for balloon pulmonary angioplasty (BPA).The current BPA strategy for chronic thromboembolic pulmonary hypertension is dilation of as many branches as possible to normalize hemodynamics and oxygenation. The shape of the guiding catheter is a major factor in achieving this. However, conventional guiding catheters are difficult to introduce into particular branches. The IL guiding catheter may be suitable; however, its utility remains unclear.We retrospectively analyzed 202 consecutive BPA sessions of 40 patients from November 2016 to October 2019 and divided these sessions into two groups: the IL group where the IL guiding catheter was used and the non-IL group where other catheters were utilized. The occurrence of lung injury was determined by the presence of bloody sputum. We compared the rates of successful introduction into target vessels and assessed for the occurrence of lung injury.The average age of enrolled patients was 60.3 ± 14.4 years, with females comprising 65%. There were 99 sessions in the IL group. The median treated branches per session differed between the 2 groups (IL group: 15 versus non-IL group: 10, P < 0.05). The occurrence of lung injury was lower in the IL group (4.0% versus 11.7%, P = 0.07). The IL group had more successful vessel insertions than the non-IL group (78.8% versus 42.7%, P < 0.01).The IL guiding catheter may be introduced into branches that cannot be accessed by conventional guiding catheters.

Erratum: Diagnosing Heart Failure from Chest X-Ray Images Using Deep Learning

An error appeared in the article entitled "Diagnosing Heart Failure from Chest X-Ray Images Using Deep Learning" by Takuya Matsumoto, Satoshi Kodera, Hiroki Shinohara, Hirotaka Ieki, Toshihiro Yamaguchi, Yasutomi Higashikuni, Arihiro Kiyosue, Kaoru Ito, Jiro Ando, Eiki Takimoto, Hiroshi Akazawa, Hiroyuki Morita, Issei Komuro (Vol. 61, No. 4, 781-786, 2020). The Figure 5on page 784 should be replaced by the following figure.

Balloon Valvuloplasty to Treat Adult Symptomatic Pulmonary Valve Stenosis with Sequential Follow-Up Using Cardiac Magnetic Resonance Imaging in Combination with Echocardiography

Pulmonary valve stenosis (PVS) accounts for approximately 10% of all congenital heart defects. Echocardiography and right heart catheterization are the gold standards for diagnosis of PVS and for assessing disease severity and responsiveness to treatment.Recently, cardiac magnetic resonance imaging (cMRI) has been established as an important tool to comprehensively evaluate cardiac structure and function; however, research into the usefulness of cMRI for PVS management is limited. Here, we describe a case of a 59-year-old female with isolated, severe PVS who was successfully treated with balloon pulmonary valvuloplasty (BPV) followed by sequential cMRI at 1 and 12 months. Exertional dyspnea and elevated plasma BNP concentration were observed 1 month after BPV; however, echocardiographic findings did not indicate recurrent stenosis or increased pulmonary valve regurgitation but an increase in mitral E/e'. cMRI demonstrated improved systolic forward flow and RV function with enlargement of LV volume, and the rapid increase in LV preload might be associated with the transient deterioration in symptoms and BNP level, which both gradually improved within 3 months after BPV. cMRI further depicted that a reduced RV mass index and increased RV cardiac output were achieved gradually during the follow-up period.In conclusion, cMRI in combination with echocardiography was sufficiently informative to follow-up this PVS patient both before and after BPV. cMRI is easily reproducible in adult patients; therefore, cMRI should be recommended for long-term follow-up in adult PVS patients.

Diagnosing Heart Failure from Chest X-Ray Images Using Deep Learning

The development of deep learning technology has enabled machines to achieve high-level accuracy in interpreting medical images. While many previous studies have examined the detection of pulmonary nodules in chest X-rays using deep learning, the application of this technology to heart failure remains rare. In this paper, we investigated the performance of a deep learning algorithm in terms of diagnosing heart failure using images obtained from chest X-rays. We used 952 chest X-ray images from a labeled database published by the National Institutes of Health. Two cardiologists verified and relabeled a total of 260 "normal" and 378 "heart failure" images, with the remainder being discarded because they had been incorrectly labeled. Data augmentation and transfer learning were used to obtain an accuracy of 82% in diagnosing heart failure using the chest X-ray images. Furthermore, heatmap imaging allowed us to visualize decisions made by the machine. Deep learning can thus help support the diagnosis of heart failure using chest X-ray images.

Association between the ratio of serum n-3 to n-6 polyunsaturated fatty acids and acute coronary syndrome in non-obese patients with coronary risk factor: a multicenter cross-sectional study

Background

Previous studies have reported that being overweight, obese, or underweight is a risk factor for ischemic cardiovascular disease (CVD); however, CVD also occurs in subjects with ideal body mass index (BMI). Recently, the balance of n-3/n-6 polyunsaturated fatty acids (PUFAs) has received attention as a risk marker for CVD but, so far, no study has been conducted that investigates the association between BMI and the balance of n-3/n-6 PUFAs for CVD risk.

Methods

We evaluated the association between n-3/n-6 PUFA ratio and acute coronary syndrome (ACS) in three BMI-based groups (< 25: low BMI, 25–27.5: moderate BMI, and ≥ 27.5: high BMI) that included 1666 patients who visited the cardiovascular medicine departments of five hospitals located in urban areas in Japan.

Results

The prevalence of ACS events was 9.2, 7.3, and 10.3% in the low, moderate, and high BMI groups, respectively. We analyzed the relationship between ACS events and several factors, including docosahexaenoic acid/arachidonic acid (DHA/AA) ratio by multivariate logistic analyses. In the low BMI group, a history of smoking (odds ratio [OR]: 2.47, 95% confidence interval [CI]: 1.40–4.35) and low DHA/AA ratio (OR: 0.30, 95% CI: 0.12–0.74) strongly predicted ACS. These associations were also present in the moderate BMI group but the magnitude of the association was much weaker (ORs are 1.47 [95% CI: 0.54–4.01] for smoking and 0.63 [95% CI: 0.13–3.10] for DHA/AA). In the high BMI group, the association of DHA/AA (OR: 1.98, 95% CI: 0.48–8.24) was reversed and only high HbA1c (OR: 1.46, 95% CI: 1.03–2.08) strongly predicted ACS. The interaction test for OR estimates (two degrees of freedom) showed moderate evidence for reverse DHA/AA ratio–ACS associations among the BMI groups (P = 0.091).

Conclusions

DHA/AA ratio may be a useful marker for risk stratification of ACS, especially in non-obese patients.

Optimal intraoperative selection of the projection of silicone breast implant using simplified cotton sizers

Background

It is occasionally difficult to accurately measure the projection of the unaffected breast in unilateral breast reconstruction and decide the optimal projection of a silicone breast implant (SBI). SBI ready-made sizers are useful for selecting the optimal SBI; however, the cost of procuring multiple types of this ready-made sizers is high. Therefore, we aimed to develop a novel technique for selecting SBIs using simplified cotton sizers, intraoperatively.

Methods

We applied the novel technique on 15 patients who underwent SBI-based breast reconstruction after simple mastectomy, among whom two or three SBI candidates had similar height and width but different projection. The breast reconstructed using a cotton SBI sizer was compared with the unaffected breast in the sitting position. We then selected the optimal SBI with a little higher projection than that of the unaffected breast. At the postoperative 1 year, we confirmed whether we could select better SBI among the prepared SBIs.

Results

Creating and applying the cotton SBI sizer required approximately 10 min in all cases. Optimal SBI selection among the prepared SBIs was seen in 14 cases; capsule contracture occurred in 1 case.

Conclusions

A simplified cotton SBI sizer is recommended because it is easy and inexpensive to develop and provides reliable assistance in identifying the optimal SBI projection.

Short-Term and Long-Term Efficacy of Drug-Coated Balloon for In-Stent Restenosis in Hemodialysis Patients with Coronary Artery Disease

The efficacy of drug-coated balloons (DCB) for in-stent restenosis (ISR) in hemodialysis (HD) patients remains unclear.We retrospectively evaluated 153 consecutive patients who underwent DCB for ISR with follow-ups for up to 3 years after the procedure between February 2014 and June 2017. Patients were divided into an HD group (n = 39) and a non-HD group (n = 114). The primary endpoint was target lesion revascularization (TLR). The secondary endpoints were all revascularizations and major adverse cardiac events (MACE) defined as cardiac death, myocardial infarction and cerebral infarction. Kaplan-Meier curves of survival free from TLR were compared between the two groups. We also performed propensity score matching and then compared the two matched groups (n = 27 in each group). The acute procedure success rate was similar for the two groups (100% versus 99.1%, P = 0.56). The incidence of TLR was higher in the HD group than in the non-HD group (41.0% versus 9.6%, P < 0.0001). The rate of revascularizations and MACE combined was significantly higher in the HD group than in the non-HD group (64.1% versus 17.5%, P < 0.0001). Kaplan-Meier analyses showed that survival free from TLR was significantly lower in the HD group than in the non-HD group both before and after propensity score matching (P < 0.0001 and P = 0.005, respectively; log-rank test).Contrary to the similar acute procedure success, recurrent ISR and MACE occurred more frequently in HD patients than in non-HD patients after DCB, which indicates poorer long-term efficacy of DCB in HD patients.

Overview of the 83rd Annual Scientific Meeting of the Japanese Circulation Society - Renaissance of Cardiology for the Creation of Future Medicine

The 83^rdAnnual Scientific Meeting of the Japanese Circulation Society was held in Yokohama, Japan, on March 29-31, 2019, just as the cherry blossoms came into full bloom. Because the environment around cardiovascular healthcare is rapidly changing, it becomes highly important to make a breakthrough at the dawn of a new era. The main theme of this meeting was "Renaissance of Cardiology for the Creation of Future Medicine". The meeting benefited from the participation of 18,825 people, and there were in-depth and extensive discussions at every session, focusing on topics covering clinical and basic research, medical care provision system, human resource development, and public awareness in cardiovascular medicine. The meeting was completed with great success, and we greatly appreciate the tremendous cooperation and support from all affiliates.

Worsening of Mitral Regurgitation by Balloon Aortic Valvuloplasty for Severe Aortic Stenosis

A 91-year-old woman was admitted to our hospital for treatment of congestive heart failure with severe aortic stenosis. After admission, she developed a high fever due to pneumonia and worsened heart failure. We could not perform transcatheter aortic valve implantation (TAVI) because of active infection; therefore, retrograde balloon aortic valvuloplasty (BAV) was urgently performed. A complete atrioventricular block and severe functional mitral regurgitation appeared suddenly after BAV in the absence of mechanical disorders. Her condition improved after several days in our intensive care unit. Pacemaker implantation and TAVI were then performed, and the patient was discharged from our hospital. MR could sometimes exacerbate after BAV in clinical practice; therefore, we set out to report this case.

Randomized comparison between 2-link cell design biolimus A9-eluting stent and 3-link cell design everolimus-eluting stent in patients with de novo true coronary bifurcation lesions: the BEGIN trial

The appropriate stent platform for treating coronary bifurcation lesions (CBLs) remains controversial. Previous bench tests have demonstrated the superiority of a 2-link cell design to 3-link cell design for creating inter-strut dilation at the side branch ostium. This randomized multicenter prospective BEGIN trial compared the biodegradable polymer-based biolimus A9-eluting stent (2-link BES) with the durable polymer-based cobalt chromium everolimus-eluting stent (3-link EES) in 226 patients with de novo CBLs. Patients with true bifurcations, defined as > 50% stenosis in the main vessel and side branch (SB) and an SB diameter > 2.25 mm, were enrolled. Guide wire re-crossing to the distal cell (near the carina) in the jailed SB and final kissing inflation were recommended. The SB angiographic endpoint was < 50% stenosis diameter. Left-main CBLs (13.5% vs. 13.0%) and 2-stent technique (30.6% vs. 22.6%) rates were similar. The primary endpoints (minimum lumen diameter at the SB ostium measured at an independent core laboratory at the 8-month follow-up) were comparable (1.64 ± 0.50 mm vs. 1.63 ± 0.51 mm, p = 0.976). There was no significant difference in composite outcomes of cardiac death, myocardial infarction, or target vascular revascularization at 12 months (7.4% vs. 8.0%, p = 0.894). Two-link BES and 3-link EES showed similar 8-month angiographic and 1-year clinical outcomes for true CBLs.

Influence of Flap Thickness on Nipple Projection After Nipple Reconstruction Using a Modified Star Flap

BACKGROUND

In nipple reconstruction, the width, length, and thickness of modified star flaps are concerns for long-term reconstructed nipple projection. However, the flap's projection has not been analyzed, based on its thickness. The aim of the present study was to investigate how flap thickness in a modified star flap influences the resulting reconstructed nipple and achieves an appropriate flap width in design.

METHODS

Sixty-three patients who underwent nipple reconstruction using a modified star flap following implant-based breast reconstruction between August 2014 and July 2016 were included in this case-controlled study. The length of laterally diverging flaps was 1.5 times their width. The thickness of each flap was measured using ultrasonography, and the average thickness was defined as the flap thickness. We investigated the correlation between the resulting reconstructed nipple and flap thickness, and the difference of the change in the reconstructed nipple projection after using a thin or thick flap.

RESULTS

The average flap thickness was 3.8 ± 1.7 (range 2.5-6.0) mm. There was a significant, linear correlation between the flap thickness and resulting reconstructed nipple projection (β = 0.853, p < 0.01). Furthermore, the difference between the thin and thick flaps in the resulting reconstructed nipple projection was significant (p < 0.01).

CONCLUSION

Measuring the flap thickness preoperatively may allow surgeons to achieve an appropriate flap width; otherwise, alternative methods for higher projection might be used.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of smoking history on the association between Eicosapentaenoic acid to arachidonic acid ratio and acute coronary syndrome: A multicenter cross-sectional study

INTRODUCTION

The association among smoking history, eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio and acute coronary syndrome (ACS) is yet to be investigated. The present study aimed to clarify the association between the EPA/AA ratio and ACS prevalence in patients admitted to the cardiology department based on their smoking history.

METHODS

We enrolled 1733 patients from five cardiology divisions located in Tokyo, Japan, and measured their levels of polyunsaturated fatty acids, including EPA and AA, from January 2004 to May 2011. We assessed the association between the EPA/AA ratio and ACS in the subgroups stratified according to smoking history (never, former, current smokers) using multivariate logistic models.

RESULTS

A high EPA/AA ratio was significantly associated with decreased odds of ACS among patients without a smoking history (adjusted odds ratio AOR=0.20, 95% CI: 0.04–0.86) but not in patients with a smoking history (former smoker, AOR=1.50, 95% CI: 0.44–5.03; current smoker, AOR=3.73, 95% CI: 0.34–40.6).

CONCLUSIONS

The EPA/AA ratio and ACS occurrence were found to be significantly associated in patients without a smoking history; however, no such association existed in patients with a smoking history.

ABBREVIATIONS

AA: arachidonic acid, ACS: acute coronary syndrome, CVD: cardiovascular disease, DGLA: dihomo-gamma-linolenic acid, DHA: docosahexaenoic acid, EPA: eicosapentaenoic acid, JELIS: Japan EPA Lipid Intervention Study, PUFA: polyunsaturated fatty acid, RAS: renin angiotensin system, TG: triglyceride.

Coronary Artery Aneurysm Caused by a Stent Fracture

Coronary stent fracture (SF) is rare as a complication of percutaneous coronary intervention (PCI), and its adverse events are increasingly being recognized with the development in devices of PCI. The major adverse events caused by SFs are in-stent restenosis due to neointimal overgrowth caused by poor drug delivery.^1,2) A coronary artery aneurysm (CAA) is a rare complication of SF, but may lead to lethal events such as acute coronary syndrome or rupture of the CAA further leading to cardiac tamponade.^3-5) However, the management of CAAs is controversial with or without SF.⁶⁾ Herein, we report a case of a CAA caused by an SF and discuss the management of CAA complicated with SF, along with a literature review. We suggest that surgical treatment should be considered the higher-priority strategy in the cases of CAA with SF as compared to CAA without SF.

Breast reconstruction of an unusual configuration using two paranemic implants

Implant-based breast reconstruction can be performed using a choice of various types of breast implants. However, cases where the breast shapes are unsuitable for implant-based reconstruction method are occasionally encountered. We present two patients with wide trunks who underwent breast reconstruction using an unusual configuration that involved a latissimus dorsi myocutaneous flap combined with two paranemic implants.

Is it possible to perform gastric endoscopic submucosal dissection without discontinuation of a single antiplatelet of thienopyridine derivatives?

BACKGROUND AND STUDY AIMS

Combined use of thienopyridine derivatives and other antithrombotic agents is reported to be a risk factor for postoperative bleeding after gastric endoscopic submucosal dissection (ESD). However, risk associated with a single thienopyridine derivative has not been evaluated. In this study, we aimed to evaluate bleeding risks of gastric ESD without discontinuation of a single thienopyridine derivative agent.

PATIENTS AND METHODS

 This multicenter, prospective, observational cohort study included patients who had undergone implantation of a coronary artery stent and who were taking a combination of aspirin antiplatelet therapy and a thienopyridine derivative agent. Enrolled patients discontinued aspirin and underwent gastric ESD without the discontinuation of a single thienopyridine derivative agent. The primary endpoint was the major bleeding complication rate after gastric ESD.

RESULTS

 Eleven patients were enrolled in this study from April 2015 to November 2016 after written informed consent was obtained. Among them, 1 patient, who had undergone surgery for a primary cardiac tumor before ESD, was excluded from the study. Ten patients underwent gastric ESD for neoplasms. En-bloc resections were achieved in all cases without intraoperative bleeding complications. Two patients experienced postoperative bleeding although neither case required a blood transfusion (95 % CI 2.5 - 55.6 %).

CONCLUSION

 En-bloc resections were possible although the postoperative bleeding rate tended to be higher in gastric ESD without discontinuation of a single thienopyridine derivative agent. Additional preventive measures are mandatory to carry out safe gastric ESD in such settings.

A Simple and Practical Method for Setting Up a Criterion of Projection of Silicone Breast Implant After Simple Mastectomy

Objective: In breast reconstruction, decision of projection of silicone breast implant in tissue expander replacement is difficult because of the need to consider several parameters that cannot be expressed in accurate numerical form. The present study aimed at a quantitative analysis based on decreased projection of the reconstructed side compared with silicone breast implant projection and to develop a new method for simple and practical decision of silicone breast implant projection. Methods: Thirty-five patients who had mammary carcinoma and were treated with simple mastectomy, tissue expander insertion, and replacement with anatomical silicone breast implant from April 2013 to March 2016 were retrospectively identified. We recorded the projection of used silicone breast implant (Pi). The projections of reconstructed breast 6 months after silicone breast implant insertion (Pr) and that of the unaffected breast during silicone breast implant selection (Pu) were measured. The difference between Pi and Pr was defined as the revised numerical value (Rev). We investigated whether Rev significantly differed according to age, body mass index, or Pu and analyzed correlations between Rev and age, Pu, and body mass index. Results: Mean Rev in all patients was 1.2 ± 0.3 cm. Rev was significantly higher in patients with higher body mass index than in those with lower body mass index (P < .01) and in patients with higher Pu than in those with lower Pu (P < .01). Significant positive correlations of Rev with body mass index and Pu were found (β = .63, P < .01 and β = .67, P < .01, respectively). Conclusions: Rev was a simple, practical, and cost-effective concept. We believe that it is a useful indicator for deciding silicone breast implant projection.

A New Criterion for the Application of 2-Stage Implant-Only Breast Reconstruction Using a Classification Based on the Rostrocaudal Distance Along the Chest Wall Between the Lowest Point of the Breast and Inframammary Fold

Objective: It is generally difficult to achieve symmetry in implant-only breast reconstruction with ptosis, and it remains unclear what quantitative criterion may be applied in cases of breast ptosis regarding the application of this modality. Our study aimed to suggest a criterion for obtaining good aesthetic outcomes and a symmetrical inframammary fold that is well-fitting for the brassiere in implant-only breast reconstruction after simple mastectomy. Methods: We classified into 3 groups 50 consecutive patients who underwent implant-only breast reconstruction that created an inframammary fold using a modified internal method after simple mastectomy. The classification was based on the rostrocaudal distance along the chest wall between the lowest point of the breast the and the inframammary fold on the contralateral side (Dc, in millimeters). Thereafter, we compared this distance on the reconstructed side (Dr, in millimeters), Dc-Dr, and projection of the implant (Pi, in centimeters) between the groups and investigated the correlation between Dr and lower (Pi < 5.0 cm) and higher Pi (Pi ≥ 5.0 cm). Results: Dr was similar to Dc in groups 1 and 2 (0 ≤ Dc < 10 mm, 40/50 [80%]); however, Dr was significantly lesser than Dc in group 3 (Dc ≥ 10 mm, 10/50 [20%]). In addition, we found significant positive correlations between Dr and lower Pi and between Dr and higher Pi. Conclusions: A Dc below 10 mm may be a good indication for implant-only breast reconstruction. Furthermore, the modality may be applied where Dc is 7 mm or less in cases with lower Pi and where Dc is 13 mm or less in cases with higher Pi.