Stabilizing effect of total ankle arthroplasty by distal translation and lateralization of talus in varus ankle deformity

BACKGROUND

In end-stage arthritis indicated for total ankle arthroplasty (TAA), full-thickness cartilage damage, subchondral bone defect/shaving, and fluttering of the talar dome occur, shortening the distance between the tibial and talar insertions of ligaments and leading to laxity of ligaments surrounding the ankle joint. Under such conditions, medial ligaments (including the deltoid ligament) would not be expected to function properly. To stabilize the ankle joint during the stance phase, medial ligament function under tension is important. This study therefore examined whether TAA contributes to lengthening of the medial tibio-talar joint as evaluated radiographically, as a preferable method for achieving tensile effects on medial ligaments.

MATERIALS AND METHODS

Twenty-four feet with end-stage varus deformity of the ankle joint that underwent TAA were retrospectively investigated, excluding cases with any malleolar osteotomy or fracture. Distance between proximal and distal insertions of medial ligaments, lateralization of the talus, and talar tilt angle under valgus/varus stress condition were evaluated pre- and postoperatively.

RESULTS

Distance between proximal and distal insertions of medial ligaments was significantly elongated after TAA. At the same time, the talus showed significant lateralization. Furthermore, talar tilt under valgus/varus stress conditions was also significantly reduced after TAA.

CONCLUSION

TAA affects distal translation and lateralization of the talus in cases of varus ankle deformity. These effects might contribute to re-providing tensile force on lax medial ligaments, improving ligament function.

Effects of prior osteoporosis treatment on the treatment response of romosozumab followed by denosumab in patients with postmenopausal osteoporosis

In patients with postmenopausal osteoporosis, prior osteoporosis treatment affected the bone mineral density increase of following treatment with 12 months of romosozumab, although it did not affect that of following treatment with 12 months of denosumab after romosozumab.

PURPOSE

To investigate the effects of prior osteoporosis treatment on the response to treatment with romosozumab (ROMO) followed by denosumab (DMAb) in patients with postmenopausal osteoporosis.

METHODS

In this prospective, observational, multicenter study, treatment-naïve patients (Naïve; n = 55) or patients previously treated with bisphosphonates (BP; n = 37), DMAb (DMAb; n = 45) or teriparatide (TPTD; n = 17) (mean age, 74.6 years; T-scores of the lumbar spine [LS] - 3.2 and total hip [TH] - 2.6) were switched to ROMO for 12 months, followed by DMAb for 12 months. Bone mineral density (BMD) and serum bone turnover markers were evaluated for 24 months.

RESULTS

A BMD increase was observed at 12 and 24 months in the following patients: Naïve (18.2% and 22.0%), BP (10.2% and 12.1%), DMAb (6.6% and 9.7%), and TPTD (10.8% and 15.0%) (P < 0.001 between the groups at both 12 and 24 months) in LS and Naïve (5.5% and 8.3%), BP (2.9% and 4.1%), DMAb (0.6% and 2.2%), and TPTD (4.3% and 5.4%) (P < 0.01 between the groups at 12 months and P < 0.001 at 24 months) in TH, respectively. The BMD increase in LS from 12 to 24 months was negatively associated with the levels of bone resorption marker at 24 months. Incidences of major fragility fractures for the respective groups were as follows: Naïve (5.5%), BP (16.2%), DMAb (11.1%), and TPTD (5.9%).

CONCLUSIONS

Previous treatment affected the BMD increase of following treatment with ROMO, although it did not affect that of following treatment with DMAb after ROMO.

Prevalence and prognosis of isolated posterior ST-segment elevation acute myocardial infarction using synthesized-V7-9 lead

Limited data exist on the prevalence and prognosis of isolated posterior ST-segment elevation acute myocardial infarction (STEMI), revealed with a posterior chest lead. Furthermore, the utility of a synthesized-V_7-9 lead in the diagnosis of STEMI is unclear; therefore, we aimed to evaluate its usefulness. We enrolled 142 consecutive patients with STEMI with the culprit lesion on the left circumflex artery (STEMI-LCx) undergoing percutaneous coronary intervention (PCI) between January 2009 and December 2019. We retrospectively checked the ST-segment change of both standard 12-lead and synthesized-V_7-9 lead in all patients with STEMI-LCx. Based on electrocardiogram (ECG) findings, isolated posterior STEMI that was only revealed in synthesized-V_7-9 lead was classified as "STEMI-LCx-synV_7-9" and the remaining as "STEMI-LCx-12ECG." The prevalence of STEMI-LCx-synV_7-9 in patients with STEMI-LCx was assessed. The incidence of all-cause death, cardiac death, and mechanical complications within 30 days, 3 months, and 1 year was also assessed according to each STEMI-LCx. STEMI-LCx-synV_7-9 and STEMI-LCx-12ECG occurred in 10 (7.0%) and 132 (93.0%) patients, respectively. No significant difference was found in patients' characteristics between the two groups. The patients with STEMI-LCx-synV_7-9 had significantly higher incidences of cardiac death within 3 months and 1 year (30.0% vs. 6.1%, P = 0.031, 30.0% vs. 7.6%, P = 0.050, respectively) and mechanical complications in each follow-up period (20.0% vs. 1.5%, P = 0.025) than those with STEMI-LCx-12ECG. STEMI-LCx-synV_7-9 was observed in 7.0% of the patients with STEMI-LCx. Our findings suggest that the synthesized-V_7-9 lead helps diagnose isolated posterior STEMI and might improve prognosis in patients with STEMI-LCx.

Myocardial salvage after ST-segment-elevation myocardial infarction: comparison between prasugrel and clopidogrel in the presence or absence of high-residual platelet reactivity

BACKGROUND

The effect of prasugrel over clopidogrel on myocardial salvage in ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) is not fully elucidated.

METHODS

Among 854 consecutive STEMI patients who underwent p-PCI, 446 patients were evaluated by two-phase (7 days and 3 months) single-photo emission computed tomography (SPECT). Patients were divided into two groups based on the loading P2Y12 inhibitor. The clopidogrel group was further divided based on the result of platelet function testing. Thus, the prasugrel group included 227 patients; the clopidogrel without high-residual platelet reactivity (HRPR) group, 109 patients; and the clopidogrel with HRPR group, 107 patients. The primary endpoint was the Myocardial Salvage Index (MSI), determined by SPECT.

RESULTS

The incidence of final TIMI 0/1 and TIMI myocardial perfusion grade 0/1 was higher in the clopidogrel with HRPR group (0.9%, 1.8%, and 7.5%, P =  .002; 19.8%, 29.4%, and 41.1%, P = .0002, in the prasugrel, clopidogrel without HRPR, and clopidogrel with HRPR groups, respectively). The MSI was significantly lower in the clopidogrel with HRPR group (48% [27-66], 44% [30-72], and 36% [15-55], P =  .006, respectively).

CONCLUSIONS

Prasugrel in STEMI patients was associated with an increased MSI compared with clopidogrel in the presence of HRPR.

Humanized NOD/SCID/IL2rγnull mice exhibit functionally augmented human regulatory T cells associated with enzymatic up-regulation of H3K27me3 in comparison with humans

Humanized non-obese diabetic/severe combined immunodeficiency/interleukin-2 receptor-γ-null (NOD/SCID/IL2rγ^null ) [humanized (huNSG)] mice engrafted with human hematopoietic cells have been used for investigations of the human immune system. However, the epigenetic features of the human regulatory T (T_reg ) cells of huNSG mice have not been studied. The objective of this study was to clarify the characteristics of human T_reg cells in huNSG mice, especially in terms of the epigenetic aspects. We compared the populations, inhibitory molecule expression and suppressive capacity of human T_reg cells in spleens harvested from the huNSG mice 120 days after the engraftment of human umbilical cord blood CD34⁺ cells with human peripheral blood mononuclear cells (PBMCs). Histone modifications and enhancer of zeste homolog 2 (Ezh2), an H3K27 methyltransferase, of human T_reg cells were quantified in huNSG mice and human PBMCs. The effect of Ezh2 inhibitor on human T_reg cells exposed to interleukin (IL)-6 was also compared between them. Human T_reg cells in the spleens of huNSG mice showed an increased proportion among CD4⁺ T cells, higher expressions of forkhead box protein 3 (FoxP3), cytotoxic T lymphocyte antigen 4 (CTLA-4) and glucocorticoid-induced tumor necrosis factor-related protein (GITR), a higher production of IL-10 and enhanced suppressive capacity when compared with those in human PBMCs. H3K27me3 and Ezh2 were specifically up-regulated in human T_reg cells of huNSG mice in comparison with those of human PBMCs. The decrease in T_reg cells induced by IL-6 exposure was attenuated in huNSG mice when compared with human PBMCs, while the difference between them was cancelled by addition of Ezh2 inhibitor. In conclusion, huNSG mice exhibit functionally augmented human T_reg cells owing to enzymatic up-regulation of H3K27me3.

Citrullinated inter-alpha-trypsin inhibitor heavy chain 4 in arthritic joints and its potential effect in the neutrophil migration

The citrullinated inter-alpha-trypsin inhibitor heavy chain 4 (cit-ITIH4) was identified as its blood level was associated with the arthritis score in peptide glucose-6-phosphate-isomerase-induced arthritis (pGIA) mice and the disease activity in patients with rheumatoid arthritis (RA). This study aimed to clarify its citrullination pathway and function as related to neutrophils. In pGIA-afflicted joints, ITIH4 and cit-ITIH4 levels were examined by immunohistochemistry (IHC), immunoprecipitation (IP) and Western blotting (WB), while peptidylarginine deiminase (PAD) expression was measured by reverse transcription-quantitative polymerase chain reaction (RT-qPCR), IHC and immunofluorescent methods. The pGIA mice received anti-lymphocyte antigen 6 complex locus G6D (Ly6G) antibodies to deplete neutrophils and the expression of cit-ITIH4 was investigated by WB. The amounts of ITIH4 and cit-ITIH4 in synovial fluid (SF) from RA and osteoarthritis (OA) patients were examined by I.P. and W.B. Recombinant ITIH4 and cit-ITIH4 were incubated with sera from healthy volunteers before its chemotactic ability and C5a level were evaluated using Boyden's chamber assay and enzyme-linked immunosorbent assay (ELISA). During peak arthritic phase, ITIH4 and cit-ITIH4 were increased in joints while PAD4 was over-expressed, especially in the infiltrating neutrophils of pGIA mice. Levels of cit-ITIH4 in plasma and joints significantly decreased upon neutrophil depletion. ITIH4 was specifically citrullinated in SF from RA patients compared with OA patients. Native ITIH4 inhibited neutrophilic migration and decreased C5a levels, while cit-ITIH4 increased its migration and C5a levels significantly. Cit-ITIH4 is generated mainly in inflamed joints by neutrophils via PAD4. Citrullination of ITIH4 may change its function to up-regulate neutrophilic migration by activating the complement cascade, exacerbating arthritis.

Usefulness of excimer laser in acute coronary syndrome with left main coronary artery: a case series

Background

Acute coronary syndrome caused by unprotected left main coronary artery (ACS-ULMCA) occlusion has a high mortality due to the formation of plaques and rich thrombi. Although excimer laser coronary angioplasty (ELCA) is effective in debulking and ablation of plaque burden and rich thrombi, its effectiveness in ACS-ULMCA remains unknown.

Case summary

We conducted percutaneous coronary intervention (PCI) using ELCA for six patients with ACS-ULMCA from February 2016 to May 2019. This case series includes a 65-year-old man who presented with sudden-onset chest pain. Angiography revealed subtotal occlusion of the left main coronary artery (LMCA). The use of a 0.9-mm ELCA catheter advanced from LMCA to the left anterior descending artery markedly improved coronary blood flow, and intravascular ultrasound revealed debulking of the plaque and thrombus. Another 79-year-old man presented with chest pain. Angiography revealed total occlusion of LMCA. Use of a 0.9-mm ELCA catheter improved coronary blood flow. Subsequent kissing balloon technique led to satisfactory results. All cases needed mechanical support (such as intra-aortic balloon pumping or percutaneous cardiopulmonary support) prior to PCI. Five patients survived finally, and one died 34 days after primary PCI.

Discussion

After stabilizing haemodynamics by mechanical support, ELCA could be a good option to improve coronary blood flow in patients with ACS-ULMCA.

Three-dimensional visualization of the left atrium by intracardiac echocardiography facilitates trans-septal catheterization and atrial fibrillation catheter ablation in cor triatriatum sinister: A case report and literature review

A key to the success of catheter ablation in complex congenital heart disease is an accurate delineation of the anatomy. Here we describe the efficiency of intracardiac echocardiogram in guiding the catheter ablation of persistent atrial fibrillation in a 55-year-old Japanese male with cor triatriatum sinister. Echo imaging provided a detailed three-dimensional anatomy of the whole left atrium and identified an ideal trans-septal puncture site that allowed catheter access to both the accessory and main chambers of the left atrium. We review similar cases from the literature. <Learning objective: Cor triatriatum sinister is a rare cardiac anomaly wherein a fibromuscular membrane divides the left atrium into two parts. An accurate delineation of the entire left atrial anatomy including the membrane by intracardiac echocardiography may facilitate the catheter ablation procedure of atrial fibrillation, especially when deciding the optimal trans-septal catheterization site to map both left atrial chambers.>.

AB0122 DETECTION OF CIRCULATING M3 MUSCARINIC ACETYLCHOLINE RECEPTOR REACTIVE TH17 CELLS IN PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME

Background:

Sjögren’s syndrome (SS) is an autoimmune disease which is characterized by lymphocytic infiltration including CD4+IL-17 producing helper T (Th17) cells to the lacrimal and salivary glands. We previously detected anti-M3 muscarinic acetylcholine receptor (M3R) antibodies (1) and M3R reactive CD4+IFNγ producing helper T (Th1) cells (2) in SS patients. Moreover, we clarified that M3R reactive Th1 and Th17 cells had pathogenic roles in the development of auto-immune sialadenitis in SS mouse model (3).

Objectives:

The purpose of this study was to identify circulating M3R reactive Th17 cells among primary SS (pSS) patients, and to determine functional properties of those cells.

Methods:

1)Peripheral blood mononuclear cells (PBMCs) were isolated from whole blood of 10 pSS patients, age gender matched 10 healthy controls (HC), and 5 IgG4-related disease (IgG4-RD) patients. According to their HLA-DRB1 typing, top 10 ranked 20 mer peptides from the full length of M3R, which were highly predicted to bind to each HLA molecules according to the immune epitope database website, were selected for each subjects. PBMCs were stimulated with these selected M3R peptides mixed for 40 hours, and M3R peptide reactive IL-17 secreting cells were detected by IL-17 enzyme-linked immunospot assay (ELISpot).

2)PBMCs from 5 pSS patients who were positive for M3R specific IL-17 secreting cells, were stimulated with selected 12-20 mer M3R peptides separately, to identify the dominant M3R peptides responsible for IL-17 secretion by ELISpot.

3)To identify whether detected IL-17 secreting cells were Th17 cells or not, isolated CD4+T cells from 3 pSS patients who were positive for M3R specific IL-17 secreting cells, were co-cultured with auto-monocyte derived dendritic cells (DCs), and stimulated with the dominant IL-17 secreting M3R peptides detected in method 2.

4)Anti-M3R antibodies were examined using ELISA method.

5)Clinical features were compared between M3R specific Th17 cells positive and negative pSS patients.

Results:

1)5 of 10 (50%) pSS patients, while none of 10 (0%) HC, and 5 (0%) IgG4-RD patients, showed significantly increased IL-17 positive spots against selected M3R peptides mixed stimulation compared with non-stimulation in ELISpot (Figure 1). M3R specific IL-17 secreting cells were detected significantly more frequently in pSS (5/10, 50%) than in HC (0/10, 0%) (p=0.03).

2)All 5 pSS patients, who were positive for M3R specific IL-17 secreting cells, showed significantly increased IL-17 positive spots against M3R AA76-95 peptides.

3)Co-culturing CD4+ T cells with DCs, stimulated with identified dominant M3R peptides in method 2, showed significantly increased spots, clarifying that IL-17 secreting cells were peripheral M3R reactive Th17 cells.

4)Titers of anti-M3R antibodies were significantly higher among M3R reactive Th17 cells positive pSS patients than negative pSS patients.

5)5 pSS patients positive for M3R reactive Th17 cells had significantly higher disease activity score (ESSDAI: 8.0±4.3) than 5 negative pSS patients (2.8±1.7) (P=0.01).

Conclusion:

We detected circulating M3R reactive Th17 cells in pSS patients using ELISpot, whose T cell epitopes were shown to be included in M3R AA76-95. Moreover, M3R reactive Th17 cells might correlate with higher disease activity and production of anti-M3R antibodies in pSS patients.

References:

[1]Tsuboi H, et al. New epitopes and function of anti-M3 muscarinic acetylcholine receptor antibodies in patients with Sjögren’s syndrome.Clin Exp Immunol2010;162:53-61

[2]Naito Y, et al. Altered peptide ligands regulate muscarinic acetylcholine receptor reactive T cells of patients with Sjögren’s syndrome.Ann Rheum Dis2005;65:269-71

[3]Iizuka M, et al. Pathogenic role of immune response to M3 muscarinic acetylcholine receptor in Sjögren’s syndrome-like sialoadenitis.J Autoimmun.2010;35:383-9

Disclosure of Interests:

None declared

Rotational Atherectomy for Severely Calcified Lesions in Patients With Left Ventricular Systolic Dysfunction: One-Year Outcomes From aSingle-Center Registry Analysis

BACKGROUND

High-risk percutaneous coronary intervention (PCI) in patients with left ventricular (LV) systolic dysfunction has been proven to induce reverse LV remodeling. However, the impact of high-risk PCI focusing on rotational atherectomy (RA) in patients with severe LV systolic dysfunction has not been completely addressed.

METHODS

Among 4339 consecutive patients who underwent PCI, 178 patients with 192 lesions were treated with RA. The reduced ejection fraction (EF) group (LVEF ≤35%) included 25 patients, the mid-range EF group (LVEF 36-50%) included 44 patients, and the preserved EF group (LVEF >50%) included 109 patients. The primary outcome was a composite of cardiac death, non-fatal myocardial infarction, target-vessel revascularization, and ischemic stroke.

RESULTS

The cumulative 1-year incidence of the primary outcome was similar among the three groups (reduced EF, 29%; mid-range EF, 25%; preserved EF, 26%; p = 0.95). After adjusting for confounding factors, the incidence of the primary outcome in the reduced EF group (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.43-2.37; p = 0.87) and the mid-range EF group (HR, 0.99; 95% CI, 0.47-1.94; p = 0.97) was similar to that in the preserved EF group. LVEF was significantly improved in the reduced EF and mid-range EF groups compared with the preserved EF group (absolute change in LVEF: 13.6 ± 11.3%, 9.0 ± 10.1%, and -0.7 ± 7.8%, respectively; p < 0.0001).

CONCLUSIONS

Reduced EF was not associated with increase in the primary outcome in patients undergoing RA. This seemed to result from the improved LV function after PCI.

SUMMARY FOR ANNOTATED TABLE OF CONTENTS

This single center analysis study investigated 1-year composite outcome of cardiac death, non-fatal myocardial infarction, target-vessel revascularization, and ischemic stroke in patients with severe LV systolic dysfunction undergoing RA compared with that in patients with preserved LV function. The cumulative 1-year incidence of the composite outcome was similar among the three groups (reduced EF, 29%; mid-range EF, 25%; preserved EF, 26%; p = 0.95). LVEF was significantly improved in the reduced EF and mid-range EF groups compared with the preserved EF group (absolute change in LVEF: 13.6 ± 11.3%, 9.0 ± 10.1%, and -0.7 ± 7.8%, respectively; p < 0.0001).

Predicting long-term freedom from atrial fibrillation after catheter ablation by a machine learning algorithm: Validation of the CAAP-AF score

BACKGROUND

Preprocedural clinical predictors of the successful maintenance of sinus rhythm may contribute to optimal treatment strategies for atrial fibrillation (AF). The CAAP-AF score, a novel simple tool scored as 0-13 points (including six independent variables) has been proposed to predict long-term freedom from AF after catheter ablation. To clarify its reproducibility, we examined the CAAP-AF score's predictive performance and then created subgroups to best predict AF recurrence by using a machine learning algorithm.

METHODS

We studied 583 consecutive patients who underwent initial AF catheter ablation at our institute (median CAAP-AF score, 5; age, 66 ± 10 years old; female, 28.3%; coronary artery disease, 10.8%; left atrial diameter, 39.9 ± 6.6 mm; number of antiarrhythmic drugs failed, 0.4 ± 0.6; nonparoxysmal AF, 45.3%). All were systematically followed up with an endpoint of atrial tachyarrhythmia recurrence after the last ablation procedure.

RESULTS

During the 1.8 ± 1.2-year follow-up, 157 patients had atrial tachyarrhythmia recurrence. Repeated procedures were performed (n = 115). Arrhythmia recurrence after the last session occurred in 69 patients. We created Kaplan-Meier curves for freedom from AF after final AF ablation for ranges of CAAP-AF scores; these confirmed the original study results. The machine learning using Classification and Regression Trees divided the patients into three categories by the risk score: low (score ≤5), intermediate (score 6-8), and high (score ≥9).

CONCLUSIONS

The CAAP-AF score was useful to stratify the atrial tachyarrhythmia recurrence risk in AF patients undergoing catheter ablation into three categories. The score should be considered when deciding whether to perform AF ablation in clinical practice.

Coronary vasospasm caused by intravenous infusion of dexmedetomidine: Unrecognized pitfall of catheter ablation procedures of atrial fibrillation

Coronary vasospasm is an emerging potentially lethal complication of catheter ablation for atrial fibrillation (AF), however, its mechanism in this setting has not been well elucidated. A 55-year-old man with symptomatic paroxysmal AF underwent pulmonary vein isolation under sedation with propofol. The procedure was completed without any complications. Fifteen months later, a repeated session was performed because of AF recurrence. Initially, a high-dose infusion of dexmedetomidine instead of propofol was administered to introduce sedation. Then, an ST-segment elevation developed in the inferior leads and the diagnosis of coronary vasospasm was made by urgent coronary angiography. A comparison of the procedural details between the first and second sessions identified dexmedetomidine, an α-2 adrenergic agonist with a short distribution half-life, as a potential cause of coronary vasospasm seen only in the second session in the same individual. Since it has been shown that α-2 adrenoreceptor-mediated vasoconstriction can involve the coronary circulation, it is thus possible that a stimulation of α-2 adrenergic receptors induced by dexmedetomidine caused a coronary vasospasm. The present case provides new insights into dexmedetomidine-induced vasospasm. Physicians should be aware of this potentially lethal side effect of dexmedetomidine which is increasingly used in the current AF ablation practice. <Learning Objective: Dexmedetomidine has become widely used during catheter ablation for atrial fibrillation since it is generally regarded as a safe drug for sedation and analgesia with fewer respiratory depressant effects compared to other agents. However, it should be noted that dexmedetomidine may cause a coronary vasospasm, especially at the time of an initial high loading-dose infusion. Physicians should be aware of this potentially lethal side effect of dexmedetomidine.>.

P1038Device implantation after catheter ablation of paroxysmal atrial fibrillation with coexisting sick sinus syndrome: Insights from the Kansai Plus Atrial Fibrillation (KPAF) study

Background

Sick sinus syndrome (SSS) and atrial fibrillation (AF) frequently coexist and interact to initiate and perpetuate each other. Several retrospective or small cohort studies have suggested that successful catheter ablation of AF may help to waive device implantations in patients with paroxysmal AF plus SSS, however, no prospective large studies are so far available on this scenario.

Purpose

We aimed to elucidate the device implantation-free survival after catheter ablation of paroxysmal AF with coexisting SSS in a prospective large-scale registry. We also determined the risk factors for device implantations after catheter ablation of paroxysmal AF.

Methods

The Kansai Plus Atrial Fibrillation (KPAF) study is a multi-center prospective registry that enrolled 5,019 consecutive patients that underwent an initial pulmonary vein isolation-based radiofrequency catheter ablation of AF. This study was comprised of 3,226 patients with paroxysmal AF registered in the KPAF study (age, 64.8±10.5 years old; female, n=999 [31.0%]; left atrial diameter [LAD], 37.5±8.0 mm; left ventricular ejection fraction [LVEF], 65.3±8.4%, CHADS2 score, 1.09±1.05). The atrial tachyarrhythmia-free and device-free survivals after catheter ablation were compared between patients with SSS (n=368; tachy-brady syndrome, 88%) and without SSS (control; n=2,858).

Results

The atrial tachyarrhythmia-free survival was almost identical between the two groups both after the first ablation session (Fig.1A) and after the last procedure with an average of 1.3±0.5 sessions. At baseline, the devices had already been implanted in 53 (14.4%) SSS and 36 (1.3%) control patients. In the remaining patients, devices were newly implanted in 54 (17.1%) SSS and 62 (2.2%) control patients during the follow-up of 3 years after the catheter ablation (Figure 1B). In the SSS group, devices were implanted predominantly within 6 months after the catheter ablation, and atrial tachyarrhythmia recurrence preceded the device implantation in 48 (89%) patients. Multivariate predictors of device implantations after the paroxysmal AF ablation included: SSS (hazard ratio [HR] 6.85, 95% confidence interval [CI] 4.61–10.19, p<0.001), an age>75 years old (HR 1.69, 95% CI 1.08–2.64, p=0.019), a female gender (HR 2.16, 95% CI 1.44–3.24, p<0.001), the LAD (mm) (HR 1.05, 95% CI 1.02–1.08, p=0.006), and the LVEF (%) (95% CI 0.96, 95% CI 0.94–0.98, p<0.001).

Figure 1

Conclusions

Device implantations could be waived in >80% of patients with SSS at 3 years of follow-up after the catheter ablation of paroxysmal AF in this real world all comer prospective registry. In addition to coexisting SSS, predictors of device implantations after paroxysmal AF ablation included: the elderly, a female gender, a large LA, and a reduced LVEF.

Acknowledgement/Funding

None

Prognostic impact of recanalizing chronic total occlusion in non-infarct related arteries on long-term clinical outcomes in acute myocardial infarction patients undergoing primary percutaneous coronary intervention

Although chronic total occlusion (CTO) in non-infarct-related arteries (non-IRAs) negatively affects long-term mortality in patients with acute myocardial infarction (AMI) who are undergoing primary percutaneous coronary intervention (PCI), the prognostic impact of successful CTO-PCI has not been completely addressed. Among 1855 consecutive patients with AMI who underwent primary PCI, those who were treated for CTO with either PCI or medical therapy were included. We evaluated the association between recanalization of CTO and long-term cardiac mortality. Of the 172 included patients, 88 underwent CTO-PCI, and the procedures were successful in 65 patients. Thus, the successfully recanalized CTO (SR-CTO) group included 65 patients; and the no recanalized CTO (NR-CTO) group, 107 patients. During the follow-up, 72 patients died, and of whom 56 (77.8%) died because of cardiac causes. The cumulative 10-year, 30-day, and 30-day to 10-year incidences of cardiac mortality were lower in the SR-CTO group than in the NR-CTO group (19.0% vs. 51.9% p = 0.004; 4.6% vs. 14.0%, p = 0.05; 15.0% vs. 44.1%, p = 0.003, respectively). After adjusting for confounding factors, the benefits of SR-CTO for the 10-year cardiac mortality remained significant compared with those of NR-CTO (hazard ratio 0.37; 95% confidence interval 0.17-0.75; p = 0.004). In conclusion, patients with SR-CTO in non-IRAs after AMI was associated with reduced long-term cardiac mortality compared with those with NR-CTO.

Impact of Nutritional and Inflammation Status on Long-Term Bleeding in Patients Undergoing Percutaneous Coronary Intervention with an Oral Anticoagulant

AIM

Patients undergoing percutaneous coronary intervention (PCI) who require both oral anticoagulant (OAC) and antiplatelet therapy (APT) are exposed to a serious risk of bleeding. The aim of this study was to clarify the relationship among nutritional and inflammation status and long-term bleeding in patients requiring both OACs and APT after PCI.

METHODS

We performed PCI in 3,718 consecutive patients between April 2011 and March 2017, 302 of whom were treated with both OACs and APT. Patients were followed for up to 3 years for bleeding events, defined as the Bleeding Academic Research Consortium (BARC) class ≥3 bleeding. We retrospectively evaluated the ability of the Geriatric Nutritional Risk Index (GNRI) and high-sensitivity C-reactive protein (hs-CRP) to detect bleeding events.

RESULTS

During a median follow-up of 1,080 days, bleeding events were observed in 53 (17.5%) patients. Bleeding events were associated with a low GNRI (≤98) (hazard ratio [HR], 3.16; 95% confidence interval [CI], 1.84-5.45; p＜0.0001) and hs-CRP level ≥2.5 mg/L (HR, 2.75; 95% CI, 1.61-4.78; p=0.0003). A low GNRI＋high hs-CRP showed a 5.12-fold increase in the incidence of BARC class ≥3 bleeding (95% CI, 2.68-9.91; p＜0.0001) compared with a normal GNRI＋low hs-CRP. The addition of the GNRI and hs-CRP to the PRECISE-DAPT score improved C-statistics from 0.67 to 0.71 and enhanced the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI, 0.36, p＜0.0001; IDI, 0.066, p＜0.0001).

CONCLUSIONS

The GNRI and hs-CRP were novel predictors of the long-term bleeding risk in patients requiring both OACs and APT after PCI.

The Early Initiation of Extracorporeal Life Support May Improve the Neurological Outcome in Adults with Cardiac Arrest due to Cardiac Events

Objective Extracorporeal life support (ECLS) is effective for improving the survival rate of patients with refractory cardiac arrest (rCA). As little data are available regarding the impact of ECLS on a favorable neurological outcome, the predictors of a favorable neurological outcome were evaluated in this study. Methods Between January 2007 and August 2016, we retrospectively recruited patients with rCA caused by cardiac events treated with ECLS in our institute. A favorable neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category score 1 at discharge. The study endpoint was the clinical outcomes and predictors of favorable neurologic patients at discharge. Results During the study period, 67 patients with CA caused by cardiac events (acute coronary syndrome, 57 patients; idiopathic ventricular fibrillation, 10 patients) were included. Of these, 20 patients (29.9%) were classified into the favorable neurological group. No marked difference was observed in the patient characteristics between those with and without a favorable outcome except for in the time from CA to starting ECLS (ECLS initiation time). A short ECLS initiation time resulted in a favorable outcome (37.8±28.1 minutes vs. 53.6±30.7 minutes, p=0.05). The cut-off time of ECLS initiation was 46 minutes, which was prolonged by the temporary return of spontaneous circulation before ECLS [odds ratio (OR), 3.69; 95% confidence interval (CI), 1.34-10.19; p=0.01] and transfer to the angiographic room (OR, 4.07; 95% CI, 1.44-11.53, p=0.008). Conclusion The early initiation of ECLS (within 46 minutes) might be associated with a favorable neurological outcome for patients with rCA caused by cardiac events.

Impact of the clinical frailty scale on mid-term mortality in patients with ST-elevated myocardial infarction

Background

"Frailty" is associated with poor prognosis in ST-elevated myocardial infarction (STEMI). However, there is little data regarding the impact of the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), a simple and semiquantitative tool for assessing frailty, on mid-term mortality in STEMI patients.

Methods

A total of 354 consecutive STEMI patients (mean age 69.8 ± 12.4 years; male 76.6%) who underwent percutaneous intervention between July 2014 and March 2017 were retrospectively reviewed. The study endpoint was mid-term mortality according to the CFS classification. Furthermore, in order to clarify the impact of CFS upon admission on mid-term mortality, the independent predictors of all-cause death were evaluated.

Results

Patients were categorized into three groups (CFS 1-3, n = 281; CFS 4-5, n = 62; and CFS 6-7, n = 11). During the study period (median 474 days), all-cause death was observed in 39 patients. After multivariate Cox regression analysis, higher CFS (adjusted hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.43-3.85, p < 0.001), higher Killip score (adjusted HR 2.46, 95%CI 1.30-5.78, p = 0.002), and lower serum albumin level (adjusted HR 4.29, 95%CI 2.16-8.51, p < 0.001) were significantly associated with an increased risk of all-cause death.

Conclusion

In conclusion, severe frailty was associated with mid-term mortality in STEMI patients who underwent PCI.

Coil embolization of pseudoaneurysm as a complication of excimer laser coronary angioplasty: insights from intravascular ultrasound and optical coherence tomography findings

The occurrence of pseudoaneurysm in the coronary artery is rare and can develop after percutaneous coronary interventions. To date, the optimal therapy, including conservative, surgical, and endovascular therapies, for pseudoaneurysm in the coronary artery remains unclear. Here, we report a case of pseudoaneurysm arising as a complication of excimer laser coronary angioplasty, which was successfully treated with stent-assisted coil embolization, after which optical coherence tomography revealed complete healing of the pseudoaneurysm. This report highlights the feasibility of stent-assisted coil embolization for coronary pseudoaneurysms involving bifurcation.

High-Normal Thyroid-Stimulating Hormone Shows a Potential Causal Association With Arrhythmia Recurrence After Catheter Ablation of Atrial Fibrillation

Background

Hypothyroidism has been shown to contribute to enhanced atrial arrhythmogenesis, resulting in atrial fibrillation (AF) development in animal models and clinical populations. We aimed to elucidate whether high thyroid‐stimulating hormone (TSH) levels are related to outcomes of catheter ablation of AF.

Methods and Results

Of 477 consecutive patients who underwent first‐time pulmonary vein isolation–based radiofrequency catheter ablation of AF, 456 with TSH above the lower limit of the normal range (age, 65.5±9.9 years; men, 73.9%; paroxysmal AF, 56.8%) were analyzed for this study. Atrial tachyarrhythmia recurrence for 3 years was compared across groups with hypothyroidism (n=23) and TSH quartile groups with euthyroidism (normal‐range TSH levels, n=433). Atrial tachyarrhythmia recurrence occurred in 179 patients (39%) after the first session. Patients with hypothyroidism had increased recurrence compared with patients with normal TSH levels (crude hazard ratio, 3.14 after the last session; P=0.001). When focusing on patients with normal TSH levels, recurrence‐free survivals after both the first and last sessions were significantly reduced in euthyroid patients with the highest quartile of TSH levels (quartile 4) compared with others (quartiles 1–3). Cox regression analysis identified high TSH levels as an independent predictor of atrial tachyarrhythmia recurrence after both the first (adjusted hazard ratio, 1.51; P=0.018) and last (adjusted hazard ratio, 1.86; P=0.023) sessions. The difference was more pronounced in patients with paroxysmal AF than in those with nonparoxysmal AF.

Conclusions

Not only hypothyroidism but also high‐normal TSH levels may be an independent predictor of atrial tachyarrhythmia recurrence after catheter ablation of AF.

Clinical and functional significance of STEAP4-splice variant in CD14+ monocytes in patients with rheumatoid arthritis

Tumour necrosis factor alpha (TNF)-α-induced adipose-related protein (TIARP) is a negative regulator of inflammation in arthritis model mice. In humans, six-transmembrane epithelial antigen of prostate 4 (STEAP4) (human counterpart of TIARP) is also expressed in CD14⁺ monocytes from patients with rheumatoid arthritis (RA). Recently, highly levels of exon 3-spliced variant STEAP4 (v-STEAP4) expression have been observed in porcine lung. The aim of this study is to elucidate the expression and functional role of v-STEAP4, comparing it with that of STEAP4, in the pathogenesis of arthritis. We identified v-STEAP4 in CD14⁺ cells. The expression of STEAP4 and v-STEAP4 was higher in patients with RA than in healthy participants. We also found that STEAP4 and v-STEAP4 were correlated positively with C-reactive protein and that their expression was decreased after treatment with an interleukin (IL)-6 antagonist in patients with RA. To investigate further the role of STEAP4 and v-STEAP4, we produced STEAP4 and v-STEAP4 over-expressing human monocytic cell lines (THP-1) for functional analysis. In the v-STEAP4 over-expressing cells, the production of IL-6 was suppressed significantly, but TNF-α was increased significantly through lipopolysaccharide (LPS) stimulation. Immunoblot analysis revealed that phosphorylated (p-)nuclear factor kappa B (NF-κB) was increased after LPS stimulation and degradation of nuclear factor kappa B inhibitor alpha (IκBα) was sustained, whereas p-signal transducer and activator of transcription 3 (STAT-3) was decreased with v-STEAP4. We identified specific up-regulation of v-STEAP4 in RA monocytes. V-STEAP4 might play a crucial role in the production of TNF-α and IL-6 through NF-κB and STAT-3 pathways, resulting in the generation of RA.

Successful Medical Treatment Using Tolvaptan of Ventricular Septal Rupture Following Myocardial Infarction

Although improved treatments for acute myocardial infarction (AMI) have considerably reduced the mortality of AMI in the past two decades, the treatment for ventricular septal rupture (VSR)-a rare but life-threatening mechanical complication of AMI-still remains quite challenging. We herein describe the case of a high-surgical-risk patient with VSR after AMI who was successfully treated using tolvaptan (a novel V₂-receptor antagonist) without any mechanical support.

cDNA microarray analysis identifies NR4A2 as a novel molecule involved in the pathogenesis of Sjögren's syndrome

To examine genes expressed specifically in labial salivary glands (LSGs) of patients with Sjögren's syndrome (SS) in comparison with those of patients with immunoglobulin (Ig)G4-related disease (IgG4-RD), and to identify the genes involved in the pathogenesis of SS. Gene expression in LSGs of SS patients, IgG4-RD patients and healthy controls (HC) was analysed by cDNA microarray. Quantitative polymerase chain reaction (qPCR) was used to validate the up-regulation of differentially expressed genes (DEGs) in SS. Protein production of the validated gene in LSGs was examined by immunofluorescence (IF) assay. The association of molecular functions of the gene with the pathological conditions in SS was examined using peripheral blood lymphocytes. Among 1320 DEGs up-regulated in SS, qPCR confirmed the up-regulation of NR4A2 in LSGs of SS compared with IgG4-RD. IF staining showed higher production of NR4A2 in nuclei of CD4⁺ T cells and interleukin (IL)-17-producing cells in LSGs of SS, compared with IgG4-RD. Over-expression of NR4A2 mRNA was observed in peripheral CD4⁺ T cells of SS patients, compared with HC. Nuclear NR4A2 expression in T helper type 17 (Th17)-polarized CD4⁺ T cells determined by cellular IF was significantly higher in SS than in HC. Importazole, an inhibitor of importin-β, inhibited nuclear transport of NR4A2 and Th17 polarization along with IL-21 expression in naive CD4⁺ T cells under Th17-polarizing conditions, but did not alter retinoic acid receptor-related orphan receptor C (RORC) expression. NR4A2 seems to promote Th17 polarization via increased expression and intranuclear localization in CD4⁺ T cells of SS patients, which could play a critical role in the pathogenesis of SS.

Comparison of Frequency and Characteristics of Patients With Atrial Fibrillation Having Ablation With Versus Without Coronary Narrowing (≥50%) by Angiography

Atrial fibrillation (AF) shares background comorbidities with coronary artery disease (CAD), including hypertension and diabetes mellitus. The aim of the study is to evaluate the prevalence, risk factors, and prognostic significance of CAD among patients who underwent catheter ablation for AF. In 544 consecutive registered patients who underwent catheter ablation for AF (CHADS2 score 1.2 ± 1.1, paroxysmal AF 57%), quantitative coronary angiography was used to detect CAD, defined as luminal narrowing of ≥50% in diameter. Univariate and multiple logistic regression analyses were applied to evaluate the risk factors of CAD. Subsequent clinical events up to 1 year were obtained in all the patients. CAD was found in 70 patients (13%). The factors associated with the presence of CAD in AF patients who underwent catheter ablation were similar to traditional coronary risk factors such as hypertension and diabetes mellitus. AF patients with CAD had a higher CHADS2 score than those without CAD (1.5 ± 1.1 vs 1.1 ± 1.0, p = 0.009). Hence, a CHADS2 score ≥1 may be an alternative risk factor to predict CAD. Previous coronary revascularization (14% with CAD vs 6% without CAD) and paroxysmal AF (69% vs 55%) were also associated with CAD. During follow-up, patients with CAD experienced acute coronary syndrome (n = 2) and coronary revascularization (n = 18); no such events were recorded in those without CAD. In addition to traditional risk factors, CHADS2 score, previous revascularization, and paroxysmal AF may be new risk factors for CAD in AF patients.

Impact of basal inferolateral scar burden determined by automatic analysis of 99mTc-MIBI myocardial perfusion SPECT on the long-term prognosis of cardiac resynchronization therapy

AIMS

Left-ventricular (LV) scarring may be associated with a poor response to cardiac resynchronization therapy (CRT). The automatic analysis of myocardial perfusion single-photon emission computed tomography (MP-SPECT) may provide objective quantification of LV scarring. We investigated the impact of LV scarring determined by an automatic analysis of MP-SPECT on short-term LV volume response as well as long-term outcome.

METHODS AND RESULTS

We studied consecutive 51 patients who were eligible to undergo 99mTc-MIBI MP-SPECT both at baseline and 6 months after CRT (ischaemic cardiomyopathies 31%). Quantitative perfusion SPECT was used to evaluate the defect extent (an index of global scarring) and the LV 17-segment regional uptake ratio (an inverse index of regional scar burden). The primary outcome was the composite of overall mortality or first hospitalization for worsening heart failure. A high global scar burden and a low mid/basal inferolateral regional uptake ratio were associated with volume non-responders to CRT at 6 months. The basal inferolateral regional uptake ratio remained as a predictor of volume non-response after adjusting for the type of cardiomyopathy. During a median follow-up of 36.1 months, the outcome occurred in 28 patients. The patients with a low basal inferolateral regional uptake ratio with a cutoff value of 57% showed poor prognosis (log-rank P= 0.006).

CONCLUSION

The scarring determined by automatic analysis of MP-SPECT images may predict a poor response to CRT regardless of the pathogenesis of cardiomyopathy. The basal inferolateral scar burden in particular may have an adverse impact on long-term prognosis.

T-bet over-expression regulates aryl hydrocarbon receptor-mediated T helper type 17 differentiation through an interferon (IFN)γ-independent pathway

Various transcription factors are also known to enhance or suppress T helper type 17 (Th17) differentiation. We have shown previously that the development of collagen-induced arthritis was suppressed in T-bet transgenic (T-bet Tg) mice, and T-bet seemed to suppress Th17 differentiation through an interferon (IFN)-γ-independent pathway, although the precise mechanism remains to be clarified. The present study was designed to investigate further the mechanisms involved in the regulation of Th17 differentiation by T-bet over-expression, and we found the new relationship between T-bet and aryl hydrocarbon receptor (AHR). Both T-bet Tg mice and IFN-γ^-/- -over-expressing T-bet (T-bet Tg/IFN-γ^-/- ) mice showed inhibition of retinoic acid-related orphan receptor (ROR)γt expression and IL-17 production by CD4⁺ T cells cultured under conditions that promote Th-17 differentiation, and decreased IL-6 receptor (IL-6R) expression and signal transducer and activator of transcription-3 (STAT-3) phosphorylation in CD4⁺ T cells. The mRNA expression of ahr and rorc were suppressed in CD4⁺ T cells cultured under Th-17 conditions from T-bet Tg mice and T-bet Tg/IFN-γ^-/- mice. CD4⁺ T cells of wild-type (WT) and IFN-γ^-/- mice transduced with T-bet-expressing retrovirus also showed inhibition of IL-17 production, whereas T-bet transduction had no effect on IL-6R expression and STAT-3 phosphorylation. Interestingly, the mRNA expression of ahr and rorc were suppressed in CD4⁺ T cells with T-bet transduction cultured under Th17 conditions. The enhancement of interleukin (IL)-17 production from CD4⁺ T cells by the addition of AHR ligand with Th17 conditions was cancelled by T-bet over-expression. Our findings suggest that T-bet over-expression-induced suppression of Th17 differentiation is mediated through IFN-γ-independent AHR suppression.

RORγt antagonist suppresses M3 muscarinic acetylcholine receptor-induced Sjögren's syndrome-like sialadenitis

We showed recently that M3 muscarinic acetylcholine receptor (M3R)-reactive CD3⁺ T cells play a pathogenic role in the development of murine autoimmune sialadenitis (MIS), which mimics Sjögren's syndrome (SS). The aim of this study was to determine the effectiveness and mechanism of action of retinoic acid-related orphan receptor-gamma t (RORγt) antagonist (A213) in MIS. Splenocytes from M3R knockout (M3R^-/- ) mice immunized with murine M3R peptide mixture were inoculated into recombination-activating gene 1 knockout (Rag-1^-/- ) mice (M3R^-/- →Rag-1^-/- ) with MIS. Immunized M3R^-/- mice (pretransfer treatment) and M3R^-/- →Rag-1^-/- mice (post-transfer treatment) were treated with A213 every 3 days. Salivary volume, severity of sialadenitis and cytokine production from M3R peptide-stimulated splenocytes and lymph node cells were examined. Effects of A213 on cytokine production were analysed by enzyme-linked immunosorbent assay (ELISA) and on T helper type 1 (Th1), Th17 and Th2 differentiation from CD4⁺ T cells by flow cytometry. Pretransfer A213 treatment maintained salivary volume, improved MIS and reduced interferon (IFN)-γ and interleukin (IL)-17 production significantly compared with phosphate-buffered saline (PBS) (P < 0·05). These suppressive effects involved CD4⁺ T cells rather than CD11c⁺ cells. Post-transfer treatment with A213 increased salivary volume (P < 0·05), suppressed MIS (P < 0·005) and reduced IFN-γ and IL-17 production (P < 0·05). In vitro, A213 suppressed IFN-γ and IL-17 production from M3R-stimulated splenocytes and CD4⁺ T cells of immunized M3R^-/- mice (P < 0·05). In contrast with M3R specific responses, A213 suppressed only IL-17 production from Th17 differentiated CD4⁺ T cells without any effect on Th1 and Th2 differentiation in vitro. Our findings suggested that RORγt antagonism is potentially suitable treatment strategy for SS-like sialadenitis through suppression of IL-17 and IFN-γ production by M3R-specific T cells.

Non-vitamin K antagonist oral anticoagulants versus warfarin for cardioversion of atrial fibrillation in clinical practice: A single-center experience

Background

Anticoagulation therapy with the vitamin K antagonist (VKA) warfarin has been demonstrated to reduce thromboembolic risk after electrical cardioversion (ECV). However, data concerning ECV with non-VKA oral anticoagulants (NOACs) is limited. The objective of this study was to determine the efficacy and safety of NOACs in patients undergoing ECV in a real-world clinical practice at a single center in Japan.

Methods

We retrospectively analyzed the data of 406 consecutive patients who underwent ECV for atrial fibrillation (AF) or flutter under anticoagulation with one of the three NOACs (n=149) or with a VKA (n=257).

Results

The CHADS2 and HAS-BLED scores were significantly higher in the VKA group, whereas the NOACs group had a tendency toward greater spontaneous echo contrast grades. After ECV, ischemic stroke occurred in three patients of the VKA group and one patient in the NOAC group, all of whom had persistent AF, indicating no significant difference in the thromboembolic event rate within 30 days following ECV. No other thromboembolic events, major bleeding, or death occurred in either group. Among the NOAC and VKA patients in whom we newly introduced an oral anticoagulant to perform ECV, the number of days leading to ECV was significantly lesser for the NOAC patients.

Conclusion

NOACs may be used as an alternative to VKAs for ECV and may allow prompt ECV in clinical practices.