Outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation With Percutaneous Left Ventricular Unloading in Fulminant Myocarditis

Fulminant myocarditis requiring peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has a high mortality rate. We investigated clinical outcomes of combined use of VA-ECMO and percutaneous left ventricular assist device (VAD) (Impella) for fulminant myocarditis in 104 consecutive patients enrolled in the Japan Registry for Percutaneous VAD (J-pVAD) between October 2017 and January 2020. Patients were followed until hospital discharge and predictors of survival were analyzed with a Cox proportional hazards model. The median support duration of combined use of VA-ECMO and Impella (ECMO/Impella) was 6 days, and the median left ventricular ejection fraction improved from 15% to 52% during support ( p < 0.0001). Overall, 66 patients (63%) survived to discharge. Multivariate analysis revealed ECMO/Impella support at a transplant center as an independent predictor of survival ( p = 0.0231). Patients treated at transplant centers had better 60 days survival rates when compared to nontransplant centers (83% vs. 55%, p = 0.005). However, baseline characteristics and treatment strategies differed between the two groups. This real-world national registry database suggested the difference in survival after ECMO/Impella support for fulminant myocarditis between transplant and nontransplant centers, which may indicate hospital variations regarding patient management, although further controlled studies are needed.

Prevalence of bleeding events in real-world Japanese registry for Percutaneous Ventricular Assist Device

PURPOSE

Bleeding complication is a critical risk factor for outcomes of acute heart failure patients requiring mechanical circulatory support (MCS), including percutaneous catheter-type heart pumps (Impella). The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) is an ongoing, large-scale, real-world registry to characterize Japanese patients requiring Impella. Here we analyzed bleeding complication profiles in patients who received Impella.

METHODS

All consecutive Japanese patients who received Impella from October 2017 to January 2020 were enrolled. The 30-day survival and bleeding complications were analyzed.

RESULTS

A total of 1344 patients were included: 653 patients received Impella alone, 685 patients received a combination of veno-arterial extracorporeal membrane oxygenation and Impella (ECPELLA), and 6 patients had failed Impella delivery. Overall 30-day survival was 67.0%, with Impella alone at 81.9% and ECPELLA at 52.7%. Overall bleeding/hematoma adverse events with a relation or not-excluded relation to Impella was 6.92%. Among them, the rates of hematoma and bleeding from medical device access sites were 1.41% and 4.09%, respectively. There was no difference between etiologies for these events.

CONCLUSION

This study represents the first 3-year survival and the safety profile focused on bleeding adverse events from the J-PVAD registry. The results show that the real-world frequency of bleeding adverse events for patients who received Impella was an expected range from previous reports, and future real-world studies should aim to expand this data set to improve outcomes and adverse events.

Three-year experience of catheter-based micro-axial left ventricular assist device, Impella, in Japanese patients: the first interim analysis of Japan registry for percutaneous ventricular assist device (J-PVAD)

Catheter-based micro-axial ventricular assist device Impella® (Abiomed, Danvers, MA) has been used in Japanese patients with drug-refractory acute heart failure (AHF) since 2017. This is the first interim analysis of the ongoing Japan Registry for Percutaneous Ventricular Assist Device (J-PVAD) to investigate the safety and efficacy of Impella support. Between October 2017 and January 2020, 823 Japanese patients, who were treated with the Impella 2.5, CP, or 5.0 pump, were enrolled. The primary endpoints were safety profiles and cumulative 30-day survival. Among them, 44.8% of patients were acute myocardial infarction with cardiogenic shock. The Impella pumps were unable to implant in 4 patients. The Impella 2.5, CP, and 5.0 pumps were used in 72.4%, 6.2%, and 16.6%, respectively, and mean support duration was 8.1 ± 10.2 days. Combination use of Impella and venoarterial extracorporeal membrane oxygenation (VA-ECMO) was applied for 387 patients (47.3%). Pump stop occurred 22 patients (2.7%). Major adverse events included hemolysis (11.2%), hemorrhage/hematoma (6.1%), peripheral ischemia (1.6%), and stroke (1.6%). The overall 30-day survival was 62.2%. Survival of patients with single Impella support was significantly higher than patients with Impella combined with VA-ECMO support (81.1% vs 49.6%; p < 0.01), who had lower blood pressure, lower left ventricular ejection fraction, and higher degree of inotropic support. Results suggest that short-term outcome of Impella support for Japanese patients was favorable with acceptable safety profiles.

Short-Term Outcomes of Impella Support in Japanese Patients With Cardiogenic Shock Due to Acute Myocardial Infarction - Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD)

BACKGROUND

The Impella^®percutaneous left ventricular assist device has been available in Japan since 2017. This is the first large-scale registry study to analyze the efficacy and safety of Impella in Japanese patients with acute myocardial infarction with cardiogenic shock (AMICS).Methods and Results: The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) has registered all consecutive Japanese patients treated with Impella. We extracted data for 593 AMICS patients from J-PVAD and analyzed 30-day survival and safety profiles. Overall 30-day survival was 63.1%. The 30-day survival of the Impella alone and Impella plus venoarterial extracorporeal membrane oxygenation (ECPELLA) groups was 80.9% and 45.7%, respectively. The Impella alone group was older and had a lower rate of cardiac arrest, milder consciousness disturbance, less inotrope use, lower serum lactate concentrations, higher B-type natriuretic peptide concentrations, and higher left ventricular ejection fraction (LVEF) than the ECPELLA group. Cox regression analysis revealed that older age and comorbid renal disturbance were common risk factors affecting 30-day mortality in both groups. Major adverse events were hemolysis (10.8%), hemorrhage/hematoma (7.6%), peripheral ischemia (4.4%), stroke (1.3%), and thrombosis (0.7%). LVEF improved in both groups during support.

CONCLUSIONS

AMICS treatment with Impella showed favorable 30-day survival and safety profiles. The survival rate of patients treated with Impella alone was particularly high. Further studies are needed to improve outcomes of patients with ECPELLA support.

Outcomes of Dilated Cardiomyopathy in Japanese Children - A Retrospective Cohort Study

BACKGROUND

There has been no nationwide survey on the prognosis of pediatric dilated cardiomyopathy (DCM) in Japan. Therefore, we designed this retrospective multicenter study to investigate the long-term survival rate in pediatric patients with DCM in Japan.Methods and Results:In this multicenter retrospective observational study, data were reviewed for 106 patients aged <18 years who had been diagnosed with DCM at any 1 of 18 Japanese institutions between 1990 and 2014. The median age at diagnosis was 2.0 years and the median duration of observation was 3.3 years. Most DCM patients were diagnosed because of symptoms of heart failure. On echocardiography, the median left ventricular end-diastolic dimension z score was 5.4 and fractional shortening was 0.10. Freedom from death or transplantation rates at 1, 3, 5, 10, and 20 years after diagnosis were 76%, 66%, 64%, 58%, and 43%, respectively. Freedom from death rates at 1, 5, 10, and 20 years after diagnosis were 81%, 75%, 72%, and 53%, respectively. The incidence of heart transplantation at 1, 5, 10, and 20 years after diagnosis was 6%, 15%, 20%, and 20%, respectively, suggesting that only 15% of patients in Japan underwent heart transplantation within 5 years of diagnosis.

CONCLUSIONS

In Japan, the prognosis of pediatric DCM is poor and the rate of heart transplantation is low.

Outcomes of Restrictive Cardiomyopathy in Japanese Children - A Retrospective Cohort Study

BACKGROUND

There has been no nationwide survey on the prognosis of pediatric restrictive cardiomyopathy (RCM) in Japan; therefore, this retrospective multicentered study was designed to investigate the long-term survival rate of pediatric patients with RCM in Japan.Methods and Results:A multicentered, retrospective observational study was performed between 1990 and 2014 and included patients diagnosed with RCM who were aged <18 years from 18 Japanese institutions. A total of 54 patients were diagnosed with RCM. The median age at diagnosis was 4.4 years, and the median duration of observation was 2.2 years at the time of this study. Of these patients, 54% had symptoms, including heart failure. Twelve patients died without heart transplantation, mostly due to heart failure. The median time to death from diagnosis was 2.5 years. Freedom from death at 1, 5, and 10 years was 91%, 68%, and 62%, respectively. Death occurred within 5 years of diagnosis in most patients. Twenty-two patients underwent heart transplantation. Freedom from heart transplantation at 1, 5, and 10 years was 77%, 58%, and 53%, respectively. Freedom from death or heart transplantation at 1, 5, and 10 years was 72%, 40%, and 34%, respectively. The presence of symptoms was a risk factor for death or transplantation.

CONCLUSIONS

The prognosis of pediatric RCM is poor, and the heart transplantation rate is low in Japan.

Poor Myocardial Compaction in a Patient with Recessive MYL2 Myopathy

Recessive mutations in the Myosin regulatory light chain 2 (MYL2) gene are the cause of an infantile-onset myopathy, associated with fatal myocardial disease of variable macromorphology. We here present the first Japanese family affected with recessive MYL2 myopathy. Affected siblings manifested typical features and the proband's autopsy findings were compatible with the diagnosis of noncompaction cardiomyopathy. The rapidly progressive clinical course of this recessive MYL2 cardiomyopathy highlights the crucial role of c-terminal tails in MYL2 protein in maintaining cardiac morphology and function.

A novel therapeutic approach for coronary inflammation and lymphatic vessels using non-invasive low-intensity pulsed ultrasound in a porcine model with DES-induced coronary hyperconstricting responses

Background

The coronary adventitia harbors lymphatic vessels (LVs). We previously demonstrated that coronary adventitial inflammation and LV dysfunction play important roles in the pathogenesis of coronary artery spasm, including drug-eluting stent (DES)-induced coronary hyperconstricting responses, in pigs and humans. However, a direct therapeutic approach to the coronary adventitia remains to be developed.

Purpose

In this study, we aimed to examine whether our novel and non-invasive therapy with low-intensity pulsed ultrasound (LIPUS) ameliorates DES-induced coronary hyperconstricting responses, and if so, what mechanisms are involved.

Methods

An everolimus-eluting stent (EES) was implanted into the left anterior descending (LAD) coronary artery in normal male pigs. They were randomly assigned to the LIPUS or the sham therapy groups. After EES implantation, in the LIPUS group, LIPUS (32 cycles, 193 mW/cm2) was applied to the heart at 3 different levels (proximal and distal stent edges and middle portion of the stent) through X-ray fluoroscopy for 20 min at each level for every other day for 2 weeks (6 days in total) (Fig. 1A, B). The sham therapy group was treated in the same manner but without LIPUS. At 4 weeks after the procedure, we performed coronary angiography to examine coronary vasoconstricting responses to intracoronary serotonin in vivo. Finally, stented coronary vessels were harvested for immunohistochemistry of vasa vasorum (vWF), LVs (LYVE-1), vascular inflammation (CD68-positive macrophages and IL-1β expression), vascular endothelial growth factor A (VEGF-A, angiogenesis marker), VEGF-C and VEGF receptor 3 (VEGFR3, lymphangiogenesis markers).

Results

Coronary vasoconstricting responses to intracoronary serotonin at the DES edges in the LAD were significantly enhanced in the sham group but were significantly suppressed in the LIPUS group, while those responses were comparable at the non-DES implanted left circumflex (LCx) coronary artery between the 2 groups (Fig. 1C, D). In addition, in vivo lymph transport speed was significantly faster in the LIPUS group than in the sham group (Fig. 1E–G). In histological analysis, the number of LVs was significantly increased in the LIPUS group compared with the sham group, whereas those of CD68 and IL-1β expressions were significantly reduced in the LIPUS group compared with the sham group. In contrast, the density of vasa vasorum was comparable between the 2 groups. Mechanistically, the extents of VEGF-C and VEGFR3 expressions were increased in the LIPUS group, whereas that of VEGF-A was comparable between the 2 groups (Fig. 1G–K). Importantly, there were significant correlations among the LV-related changes and enhanced coronary vasoconstricting responses.

Conclusion

These results provide the first evidence that the LIPUS therapy ameliorates DES-induced coronary hyperconstricting responses in pigs in vivo through structural and functional alterations of LVs (Fig. 1L).

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical implications of coronary artery morphology of patients with ischemia and non-obstructive coronary artery disease (INOCA) -An intracoronary OCT study-

Introduction

Ischemia and non-obstructive coronary artery disease (INOCA), including microvascular spasm (MVS) and epicardial spasm, has recently attracted much attention, for which in vivo imaging evaluation for coronary artery morphology is warranted for better understanding of this disorder. Besides the improved diagnostic accuracy of optical coherence tomography (OCT) for coronary plaques, we have recently demonstrated its capability for in vivo visualization of coronary adventitial vasa vasorum (VV) and the enhanced VV formation in patients with epicardial spasm.

Purpose

We aimed to examine OCT-delineated morphological characteristics in patients with INOCA in vivo.

Methods

A total of 335 consecutive INOCA patients, who underwent pharmacological spasm provocation tests, lactate sampling, and OCT imaging over the entire length of the left anterior descending (LAD) coronary arteries, were enrolled at our institute over 68 months from April 2013. They were classified into 4 groups; control with non-cardiac chest pain, MVS, diffuse spasm (DS), or focal spasm (FS) (Fig. 1A). MVS was diagnosed when negative lactate extraction ratio (coronary orifice &lt; coronary sinus) was detected despite the absence of epicardial spasm during the spasm provocation test. DS was defined as epicardial spasm induced in more than 2 coronary segments in LAD, and FS as epicardial spasm in one segment. Quantitative analyses for adventitial inflammation and atherosclerotic changes were performed by calculating VV density and %area stenosis (AS) on OCT (Fig. 1B, E). Furthermore, index of microcirculatory resistance (IMR), a marker of microvascular disorder with a cut-off value of ≥25, was measured during intravenous infusion of adenosine, which was then correlated with VV densities in the MVS and DS groups. Coronary plaque with a necrotic core was classified as fibroatheroma (FA), and the number of OCT frames with internal VV (IVV) in the atheroma was counted.

Results

VV density was significantly higher in MVS as compared with the controls (Fig. 1B). DS was most prevalent in INOCA (Fig. 1A) with highest VV density (Fig. 1B). Patients with IMR≥25 were predominantly distributed with a gradual increase in the MVS, DS, and FS groups, but none in the controls (Fig. 1C). Importantly, there was a significant positive correlation between VV densities and IMR in the MVS and DS groups (Fig. 1D). In addition, FS had the largest plaque size and showed the highest prevalence of FA and IVV (Fig. 1E–G).

Conclusions

These results indicate that MVS and DS are characterized by vasomotion abnormalities associated with adventitial inflammation and microvascular disorder, while FS by vulnerable atherosclerotic phenotype, suggesting that OCT may be useful for screening high-risk populations in INOCA.

Figure 1

Funding Acknowledgement

Type of funding source: None

Relationship between post-IVIG IgG levels and clinical outcomes in Kawasaki disease patients: new insight into the mechanism of action of IVIG

INTRODUCTION/OBJECTIVES

The dosing of intravenous immunoglobulin (IVIG) therapy for Kawasaki disease (KD) has been a matter of debate for decades, with recent studies implicating that larger doses lead to better outcomes. Despite this, few have investigated post-IVIG infusion immunoglobulin G (IgG) levels in relation to outcomes of KD such as response to IVIG and development of coronary artery abnormalities (CAAs). The present study investigated how varying levels of post-infusion IgG affected these outcomes.

METHOD

We collected demographic and laboratory data, including post-infusion IgG, from children with KD who were admitted to six hospitals in Japan between 2006 and 2012. We conducted multivariate analyses to examine the relationship between independent variables and non-response to IVIG and development of CAAs. We used random forest, a decision tree-based machine learning tool, to investigate the marginal effect of varying post-infusion IgG levels on non-response to IVIG and development of CAAs.

RESULTS

Of 456 patients included in the study, 130 (28.5%) were non-responders and 38 (8.3%) developed CAAs. Sodium, post-infusion IgG, and AST were significantly associated with non-response. Post-infusion IgG and sodium were significantly associated with CAA development. The random forest plots revealed a decrease in non-response and CAA rates with increasing post-infusion IgG until post-infusion IgG was near the median (2821 mg/dL), after which the non-response and CAA rates leveled off.

CONCLUSIONS

Greater post-infusion IgG is associated with better response to IVIG and decreased CAA development in KD patients, but this effect levels off at post-infusion IgG levels greater than the median. Key points • Though previous studies have shown that post-intravenous immunoglobulin (IVIG) infusion immunoglobulin G (IgG) is associated with non-response to IVIG therapy and coronary artery abnormality (CAA) development in Kawasaki disease (KD) patients, no study has investigated the relationship between varying levels of post-infusion IgG and these clinical outcomes. • Our study showed that non-response to IVIG therapy and CAA development in Kawasaki disease patients follow a decreasing trend with increasing post-infusion IgG at post-infusion IgG levels below the median. • At values of post-infusion IgG greater than the median, non-response and CAA development rates remain relatively constant with increasing post-infusion IgG. • Our study suggests that when post-infusion IgG is greater than the median, IgG may have fully bound to the therapeutic targets of KD, and in these patients, there may be limited benefit in administering additional IVIG.

P1753 Echocardiographic assessment of prosthetic aortic valve in children

Introduction

Although the diagnostic utility of Doppler-derived hemodynamic parameters of prosthetic aortic valve (PAV) for detecting prosthetic dysfunction has been demonstrated in adults, interpreting these parameters in children is difficult, as the relative size of PAV varies more greatly in them than in adults. We aimed to elucidate how the Doppler-derived hemodynamic parameters change as the PAV size decreases relative to the somatic growth of children.

Methods

We reviewed 11 echocardiographic examinations of 9 mechanical PAVs in 8 children. The median age at echocardiographic examination was 10.2 (0.5-17.7) years. Underlying diagnoses leading to aortic valve replacement were aortic regurgitation due to dysplastic aortic valve in 3 children, Marfan syndrome in 1, persistent truncus arteriosus in 1, and aortic stenosis associated with interrupted aortic arch/coarctation of the aorta in 3. The PAV functioned normally in all examinations. PAV size was 19 mm in 8 examinations and 17 mm in 3 examination, which was standardized to body surface area at the examination by calculating z-scores based on previously published normative data of aortic valve diameter. We assessed the Doppler-derived hemodynamic parameters, namely peak velocity, mean pressure gradient, and accerelation time of the transprosthetic flow, the velocity-time integral (VTI) ratio of the left ventricular outflow to the transprosthetic flow, and effective orifice area (EOA) of the PAV calculated by using the continuity equation. The Pearson correlation coefficients between the PAV size z-score and Doppler-derived hemodynamic parameters of the normally functioning PAVs were evaluated. A p-value of &lt;0.05 was considered statistically significant.

Results

All the Doppler-derived hemodynamic parameters except for EOA had a statistically significant correlation with PAV size z-score (Pearson correlation coefficients: peak velocity, -0.76; mean pressure gradient, -0.70; acceleration time, -0.66; and VTI ratio, 0.76). Multivariate analysis revealed that VTI ratio was the sole parameter that independently correlated with PAV size z-score.

Conclusions

VTI ratio, which is theoretically less dependent on cardiac preload than other hemodynamic parameters, strongly reflects BSA-indexed PAV size. Disproportionately decreased VTI ratio in relation to PAV size might indicate prosthetic obstruction in children with PAV.

Abstract P1753 Figure. Correlation of PAV size and VTI ratio

92Transcatheter aortic valve implantation improves cerebral blood flow and cognitive function in elderly patients with aortic stenosis - Brain perfusion SPECT imaging study

Background

Cognitive impairment and depression are commonly noted in elderly frail patients with severe aortic stenosis (AS). However, their mechanisms and reversibility after treatment remain remain to be examined.

Purpose

In this study, we examined whether transcatheter aortic valve implantation (TAVI) increases cerebral blood flow (CBF) in cognitive/emotional brain areas, such as the hippocampus, in the elderly patients with severe AS.

Methods

We examined consecutive 15 right-handed patients with severe AS who were eligible for TAVI (median age 83.2 years, 12 (80%) women). We evaluated the following assessments both at baseline and 3 months after TAVI. Frailty was evaluated based on Fried scale, which consists of 5 items, including gait speed, cognitive function, weight loss, exhaustion, and inactivity. Frail and pre-frail were defined as greater than 3 and 1∼2 in the scale, respectively. Cognitive and emotional status were evaluated with Logical Memory (LM) II, Mini Mental State Examination (MMSE), and geriatric depression scale (GDS). Lower LM II (less than 4 points) and MMSE (less than 24 points) and higher GDS (more than 6 points) indicate worse memory, general cognitive function, and depressive symptoms, respectively. CBF images were recorded with 99mTc single-photon emission computed tomography and were analyzed using SPM12. Briefly, CBF images were firstly normalized to the standard Montreal Neurological Institute space. Then, a voxel-wise parametric analysis was conducted between normalized CBF images at baseline and those after TAVI (P<0.005 at each voxel). Continuous variables were presented as mean ± standard error (SE). Normality was assessed using the Shapiro-Wilk test. Continuous variables were compared with the use of paired t test. Linear mixed-model analysis was performed to evaluate changes in neuropsychological tests and CBF over time.

Results

In the present study, all patients were not robust but pre-frail (47.3%) or frail (53.7%). LM II score was significantly improved at 3 months after TAVI compared with baseline (baseline, 8.7 vs. 3 months, 13.8, P<0.01) (Figure A), whereas no significant changes in MMSE or GDS scores were noted (baseline, 24.6 vs. 3 months, 25.2 for MMSE; baseline, 4.3 vs. 3 months, 4.2 for GDS). Importantly, although no patients showed clinical symptoms or signs for transient ischemic attack or stroke after TAVI, CBF in the local regions, including the right hippocampus, was significantly increased after TAVI compared with baseline (P<0.005 at each voxel) (green arrowheads) (Figure B). Furthermore, CBF in the right hippocampus were positively correlated with LM II scores (P=0.017) (Figure C).

Figure 1

Conclusions

These results provide the first evidence that TAVI improves cerebral perfusion (especially that in the hippocampus) and cognitive functions in elderly patients with severe AS.

P3575Clinical importance of fractional flow reserve in patients with organic coronary stenosis and vasospastic angina

Background

Vasospastic angina (VSA), which is one of the important functional cardiac disorders, may also play a role in the pathogenesis of atherosclerosis. Conversely, organic coronary stenosis is also known as an independent predictor for poor clinical outcomes in VSA patients. Although VSA patients have a variable degree of organic coronary stenosis in clinical setting, the functional importance of organic stenosis in those patients remains to be elucidated.

Purpose

The aim of this study was to examine the clinical importance and prognostic impact of fractional flow reserve (FFR) in patients with VSA and organic coronary stenosis.

Methods

We enrolled 236 consecutive patients with suspected vasospastic angina who underwent acetylcholine provocation test for coronary spasm (M/F 148/88, 63.6±12.0 [SD] yrs.). Among them, 175 patients (74.1%) were diagnosed as having VSA, while the remaining non-VSA patients were regarded as controls (Group-C, n=61). We divided the VSA patients into 3 groups based on angiographical findings and FFR values; VSA with no organic stenosis (>50% luminal stenosis) (Group-N, n=110), organic stenosis and high FFR (≥0.80) (Group-H, FFR 0.87±0.05, n=36), and organic stenosis and low FFR (<0.80) (Group-L, FFR 0.71±0.07, n=29). We evaluated the incidence of major adverse cardiovascular events (MACE), including cardiovascular death (CVD), non-fatal myocardial infarction (MI), urgent percutaneous coronary intervention (PCI), and hospitalization due to unstable angina pectoris (UAP) during the median follow-up period of 656 days.

Results

The groups with organic stenosis (Groups H and L) were characterized by higher prevalence of diabetes mellitus (Group-C/N/H/L, 23.0/20.9/44.4/34.5%, P=0.03) and dyslipidemia (Group-C/N/H/L, 37.7/39.1/50.0/65.5%, P=0.03) as compared with Group-C. After provocation test, all VSA patients received calcium channel blockers (CCBs). In addition, 20 days (median) after provocation test, 26 patients (92.9%) in Group-L underwent elective PCI with coronary stents, while no patient underwent PCI in Groups N or H. The incidence of MACE during follow-up was significantly higher in Group-L (Group-C/N/H/L; 1.6/3.6/5.6/27.6%, log-rank P<0.001), whereas clinical outcomes were comparable among the remaining 3 groups (Figure). Importantly, all 8 patients with MACE in Group-L had poor outcomes (CVD/MI/urgent PCI/UAP; 2/1/3/2) despite complete revascularization and the prevention of coronary spasm with CCBs, indicating that they might be resistant to standard contemporary therapies. They were characterized by less frequent use of angiotensin convert enzyme inhibitor (0 vs. 47.6%, P=0.02) and higher prevalence of multi-vessel organic lesions (37.5 vs. 4.8%, P=0.052) compared with those without MACE.

Figure 1

Conclusions

These results provide the first evidence that evaluation of coronary functional abnormalities with FFR is useful for making therapeutic strategies in VSA patients with organic coronary stenosis.

P4158Marked impairment of endothelium-dependent digital vasodilatations in patients with microvascular angina compared with those with vasospastic angina

Background/Introduction

Nitric oxide (NO) and endothelium-dependent hyperpolarization (EDH) factor are the major endothelium-derived relaxing factors. NO plays an important role in conduit arteries, while the importance of EDH factor increases as the vessel size decrease in patients with microvascular angina (MVA) compared with those with vasospastic angina (VSA) remains to be fully elucidated.

Purpose

We evaluated the roles of NO and EDH factor in conduit (brachial) arteries and resistance (digital) arteries of the patients with MVA, VSA and comorbid MVA+VSA patients.

Methods

We enrolled 39 patients who underwent diagnostic cardiac catheterization and divided them into 3 groups based on acetylcholine (ACh) provocation test, index of microcirculation resistance (IMR), and coronary flow reserve (CFR); MVA (N=9, mean age 59.9±3.5 years), VSA (N=12, mean age 61.3±1.8 years), and comorbid MVA+VSA (N=18, mean age 64.0±2.2 years). Endothelium-dependent brachial and digital vasodilatations in response to intra-arterial infusion of bradykinin (BK, 25, 50, and 100 ng/min for 2 min) were simultaneously measured by ultrasonography and peripheral arterial tonometry, respectively. Measurements were repeated after oral administration of aspirin (486 mg) and intra-arterial infusion of NG-monomethyl-L-arginine (L-NMMA, 8μmol/min for 5 min) in order to inhibit the effects of vasodilator prostaglandins and NO, respectively. Finally, endothelium-independent brachial and digital vasodilatations in response to sublingual nitroglycerin (NTG, 0.3 mg) were measured in the same manner.

Results

In the brachial artery, dose-dependent vasodilatations to BK were comparable among the 3 groups, and L-NMMA equally attenuated the responses to BK (Figure 1). Endothelium-independent brachial vasodilatation in response to NTG was also comparable among the 3 groups. Surprisingly, dose-dependent digital vasodilatations to BK were almost absent in MVA patients compared with VSA or comorbid MVA+VSA group (Figure 2). Furthermore, the digital vasodilatations were unaffected by L-NMMA in VSA group, but were significantly reduced in comorbid MVA+VSA group (VSA, 16.8±15.1% vs. MVA+VSA, −0.23±6.2%, P<0.05), suggesting reduced EDH and compensatory role of NO in the latter group. In contrast, endothelium-independent digital vasodilatation in response to NTG was comparable among the 3 groups.

The main results of this study

Conclusions

These results provide the first evidence that endothelium-dependent digital vasodilatations (both NO and EDH factor) are markedly impaired in MVA patients compared with VSA or comorbid MVA+VSA patients, whereas the responses are comparable in the brachial artery among the 3 groups, suggesting the involvement of severe endothelial dysfunction in the pathogenesis of MVA.

2381Low-intensity pulsed ultrasound ameliorates DES-induced coronary adventitial inflammation and hyperconstricting responses in pigs in vivo - A novel non-invasive therapy for coronary inflammation

Background

We previously demonstrated that coronary adventitial inflammation plays important roles in the pathogenesis of coronary artery spasm, including drug-eluting stent (DES)-induced coronary hyperconstricting responses, in pigs and humans. Indeed, the coronary adventitia has recently attracted much attention as the important site for vascular inflammation. However, a direct therapeutic approach to the coronary adventitia remains to be developed. We have developed a non-invasive low-intensity pulsed ultrasound (LIPUS) therapy for angina, which exerts anti-inflammatory effects through improved coronary microcirculation.

Purpose

In this study, we aimed to examine whether our LIPUS therapy ameliorates DES-induced coronary hyperconstricting responses in pigs in vivo, and if so, what mechanisms are involved.

Methods

An everolimus-eluting stent (EES) was implanted into the left anterior descending (LAD) coronary artery in normal male pigs. They were randomly assigned to the LIPUS or the sham therapy groups. After EES implantation, in the LIPUS group, LIPUS (32 cycles, 193 mW/cm2) was applied to the heart at 3 different levels (proximal and distal stent edges and middle portion of the stent) through X-ray for 20 min at each level for every other day for 2 weeks (6 days in total) (Figs. 1A, 1B). The sham therapy group was treated in the same manner but without LIPUS. At 4 weeks after the procedure, we performed coronary angiography to examine coronary vasoconstricting responses to intracoronary serotonin in vivo. Finally, stented coronary vessels were harvested for immunohistochemistry of vasa vasorum, lymphatic vessels (LYVE-1), sympathetic nerve fibers (SNF), vascular inflammation (macrophages and IL-1β expression), Rho-kinase expression and activity as evaluated by phosphorylated myosin phosphatase target subunit-1 (pMYPT-1).

Results

Coronary vasoconstricting responses to intracoronary serotonin were significantly enhanced in the sham therapy group but were significantly suppressed in the LIPUS group at the DES edges in the LAD, whereas those responses were comparable at the non-DES implanted segments in the left circumflex (LCx) coronary arteries between the 2 groups. (Figs. 1C, 1D). Furthermore, in vivo lymph transport speed was significantly faster in the LIPUS group than in sham group (Figs. 1E–1G). Histological analysis showed that except vasa vasorum formation, the number of lymphatic vessels, adventitial inflammatory cells infiltration, Rho-kinase expression and activity were all significantly enhanced in the sham therapy group and were significantly suppressed in the LIPUS group (Figs. 1G–1K).

Figure 1

Conclusion

We were able to develop a non-invasive LIPUS therapy for coronary functional abnormalities caused by chronic adventitial inflammation in pigs in vivo, for which multiple beneficial effects appear to be involved (Fig. 1L).

3332Exercise training ameliorates vasodilator capacity of coronary microvessels in patients with vasospastic angina - A new therapeutic approach for the coronary functional disorder

Background

We have recently demonstrated that coronary vasospasm could develop in both epicardial coronary arteries and intramuscular coronary microvessels in patients with vasospastic angina (VSA). However, it remains to be examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients and if so, whether exercise training could ameliorate vasodilator capacity of coronary microvessels on the top of calcium channel blockers. The effectiveness of exercise training is established for organic coronary artery disease but remained to be examined for VSA.

Purpose

We thus examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients without organic coronary stenosis using an adenosine-stress dynamic computed tomography perfusion (CTP) that can measure absolute value of myocardial blood flow (MBF). We also examined whether exercise training ameliorates not only vasodilator capacity of coronary microvessels but also exercise capacity and frequency of angina attack.

Methods

In the first protocol, we measured MBF using CTP in consecutive 32 VSA patients with acetylcholine-induced diffuse coronary spasm in the left anterior descending coronary arteries (LAD) and 12 non-VSA controls. In the second protocol, we conducted a randomized controlled trial (RCT; Exercise VSA trial, UMIN: ehz745.008423996), where 20 VSA patients were randomly assigned to either exercise group (Ex group: supervised exercise training session for 30-min using bicycle ergometer, once/week at the hospital and more than 3 times/week at home) or non-exercise group (Non-Ex group) (n=10 each) (Figure A). Before and 3 months after exercise training, we measured MBF with adenosine-stress dynamic CTP and peak VO2 by cardiopulmonary exercise tests, and also assessed angina attack with Seattle Angina Questionnaire (SAQ).

Results

In the first protocol, CTP showed that adenosine-stress MBF was significantly decreased in the VSA group compared with the non-VSA group (VSA, 137.2±6.6 vs. Non-VSA, 174.4±10.7 ml/100g/min, P<0.01) (Figure B), although patient characteristics were comparable between the 2 groups. In the second protocol, exercise training was performed safely in all patients, and RCT showed that MBF was significantly increased in the Ex group compared with the non-Ex group (Figures C, D), although patient characteristics were also comparable between the 2 groups. Furthermore, peak VO2 was significantly increased in the Ex group compared with the non-Ex group (Figure E), and frequency of angina was significantly decreased in the Ex group compared with the non-Ex group (Figure F). Finally, there was a significant positive correlation between the extents of the changes in peak VO2 and the SAQ score for angina frequency in the Ex group (P<0.01, R=0.67).

Figures

Conclusions

These results provide the first evidence that vasodilator capacity of coronary microvessels is impaired in VSA patients, which can be ameliorated by exercise training.

P4156Coexistence and prognostic impacts of epicardial and microvascular coronary dysfunctions in patients with chest pain and unobstructive coronary artery disease - Involvement of Rho-kinase activation

Background

Although the importance of coronary functional abnormalities has been emerging, including epicardial coronary spasm (vasospastic angina, VSA) and coronary microvascular dysfunction (CMD), comprehensive evaluation of the abnormalities in the same population remains to be examined.

Purpose

We examined the significance of coronary functional abnormalities in a comprehensive manner for both epicardial and microvascular coronary arteries in patients with chest pain and unobstructive coronary artery disease (CAD) as well as their prognostic impacts.

Methods and results

We prospectively enrolled 187 consecutive patients with suspected angina and unobstructive coronary arteries (M/F 113/74, 63.2±12.3 [SD] yrs.). We performed acetylcholine (ACh) provocation tests for coronary spasm, followed by functional tests for coronary microvascular function, including coronary flow reserve (CFR) and index of microcirculation resistance (IMR) during hyperemic state induced by intravenous adenosine. Among the 187 patients, ACh test identified 128 patients with VSA (68%). There was no significant difference in age, sex, or prevalence of traditional coronary risk factors between the non-VSA and the VSA groups. The median IMR value was significantly higher in the VSA group than in the non-VSA group [17.5 (12.0, 25.3) vs. 14.7 (10.7, 17.8), P=0.02], whereas CFR values were comparable between the 2 groups [2.51 (1.72, 3.35) vs. 2.66 (1.85, 3.64), P=0.34]. During the median follow-up period of 893 days, major adverse cardiac events (MACE), including cardiac death, non-fatal myocardial infarction, and hospitalization due to unstable angina pectoris, occurred in 10 patients (5.3%). Multivariable analysis revealed that IMR correlated with the incidence of MACE [hazard ratio (HR) (95% confidence interval), 1.05 (1.02–1.09), P=0.002] and receiver-operating characteristics curve analysis identified IMR of 18.0 as the optimal cut-off value for the incidence of cardiac events. When we divided the patients into the following 4 groups according to the cut-off value of IMR (>18) and the presence or absence of VSA; G1, IMR <18 without VSA (n=45); G2, IMR ≥18 without VSA (n=14); G3, IMR <18 with VSA (n=67); and G4, IMR ≥18 with VSA (n=61), the Kaplan-Meier survival analysis showed a significantly worse prognosis in G4 compared with other 3 groups (HR [95% CI] 6.23 [1.21–118.46], P=0.002) (Figure 1). Importantly, intracoronary administration of fasudil, a Rho-kinase inhibitor, significantly ameliorated IMR in G4 (P<0.0001) (Figure 2A), and %changes in IMR in response to intracoronary fasudil were more evident in G4 compared with other 3 groups (P<0.0001) (Figure 2B).

Conclusions

These results provide the first evidence that in patients with chest pain and unobstructive CAD, epicardial coronary spasm and increased microvascular resistance are frequently coexisted with worse long-term prognosis, for which Rho-kinase activationmay be involved.

Ecthyma gangrenosum in a 3-year-old boy post-heart transplantation

Ecthyma gangrenosum (EG) is a serious bacterial infection in immunocompromised patients. EG in transplant recipients is rarely reported and may go unrecognized, which may delay initiation of appropriate treatment. We report a case of EG in a pediatric heart transplant recipient who was treated successfully with antibiotics and surgical debridement.

Cardiac Rhythm Disturbances in Heterotaxy Syndrome

OBJECTIVE

Heterotaxy syndrome is associated with complex cardiac malformations and cardiac conduction system abnormalities. Those with right atrial isomerism (RAI) have dual sinus nodes and dual atrioventricular nodes predisposing them to supraventricular tachycardia (SVT). Those with left atrial isomerism (LAI) lack a normal sinus node and are at risk of sinus node dysfunction (SND) and atrioventricular block (AV block). We report the occurrence and risk factors associated with arrhythmias in heterotaxy syndrome.

METHODS

A retrospective review of all heterotaxy syndrome patients born and treated at our institution between 2000 and 2014 was performed.

RESULTS

A total of 40 patients were identified; 16/40 (40%) with LAI and 24/40 (60%) with RAI. There were 12 deaths during follow-up [LAI 3/16 (19%), RAI 9/24 (38%); p = 0.30]. Twenty-one patients had arrhythmias during a mean follow-up period of 5.4 years; 14/16 (87%) in LAI and 7/24 (29%) in RAI (p < 0.001). Freedom from arrhythmia at 1,3,5 years of age was 75.0%, 37.9%, 22.7% in LAI, and 83.3%, 77.5%, 69.6% in RAI, respectively(p = 0.00261). LAI had a three-fold increase in developing arrhythmias. Left atrial isomerism was the only factor identified to be associated with arrhythmia occurrence.

CONCLUSIONS

Arrhythmias were commonly seen in heterotaxy syndrome particularly in left isomerism with more than half of the patients having arrhythmias by 3 years of age. Atrial situs was the only risk factor identified to be associated with arrhythmias, and close follow-up is warranted in these patients.

Identification of liver fibrosis using the hepatic vein waveform in patients with Fontan circulation

AIM

Liver fibrosis caused by congestive hepatopathy has emerged as an important complication after Fontan procedure. We evaluated the utility of the hepatic vein (HV) waveform using Doppler ultrasound for identification of liver fibrosis in Fontan patients.

METHODS

We investigated the HV waveforms in 41 Fontan patients and assessed correlations with clinical parameters, liver fibrosis markers, and hemodynamic data.

RESULTS

Based on our preliminary analysis of 64 adult patients with chronic liver disease who underwent liver biopsy, we classified HV waveforms into five types with reference to the degree of flattening (from type 1, normal triphasic waveform; to type 5, a monophasic waveform indicating cirrhosis), and confirmed a significant correlation between waveform pattern and fibrosis stage. Notably, we detected HV waveforms in all of the Fontan patients and classified them into five types. The HV waveform pattern positively correlated with γ-glutamyl transferase and hyaluronic acid levels, and negatively correlated with albumin level and platelet count, but did not correlate with central venous pressure or brain natriuretic peptide level, suggesting that HV waveform could reflect pathophysiological changes in the liver without being affected by hepatic congestion. The highest area under the receiver operating characteristic curve of the HV waveform for detecting advanced liver fibrosis, as defined by ultrasonic findings and clinical features, was 0.829 (81.8% sensitivity, 73.3% specificity), which was higher than that of other non-invasive fibrosis markers.

CONCLUSIONS

Hepatic vein waveforms change in accordance with liver fibrosis progression in Fontan patients, and can be a useful indicator of liver fibrosis after the Fontan procedure.

Identification of a Novel Titin Variant Underlying Myocardial Involvement in Neurofibromatosis Type 1

Because of the rare co-occurrence, it remains a question whether cardiomyopathy is a true association of neurofibromatosis type 1. A boy with café-au-lait spots manifested restrictive cardiomyopathy. Whole exome sequencing confirmed the genetic diagnosis of neurofibromatosis and further identified a novel titin (TTN) missense variant. The significance of the variant is supported by its de novo origin, in silico predictions, and evolutionary conservation. Modern genetics raises an intriguing explanation for the unexpected phenotype and adds to the evolving role of TTN variants in cardiomyopathy.

Effect of i.v. immunoglobulin in the first 4 days of illness in Kawasaki disease

BACKGROUND

Although early treatment of Kawasaki disease (KD) with i.v. immunoglobulin (IVIG) is expected to prevent coronary artery abnormalities, the effectiveness of IVIG by day 4 of illness remains to be determined.

METHODS

This was a multi-institutional, retrospective cohort study. Patients diagnosed with KD at ≤4 days of illness were divided into two groups: those who received initial IVIG before and on day 5 of illness. Baseline characteristics were adjusted using propensity scores. The primary endpoint was the need for additional treatment.

RESULTS

Of 339 patients diagnosed with KD by day 4, 181 and 158 received IVIG before and on day 5 of illness, respectively. Patients in the early treatment group had more adverse prognostic factors: infancy, early onset of the principal symptoms, and abnormal laboratory data. We thus adjusted baseline characteristics before treatment decisions using propensity scores. Propensity score matching of the two groups yielded 100 observations. More patients required additional treatment in the matched early treatment group: 37% vs 24% (adjusted OR, 1.7; 95%CI: 1.06-2.8; P = 0.047). The difference was more pronounced for risk of relapse after initial resolution of fever: 14% vs 5.0% (adjusted OR, 3.2; 95%CI: 1.3-7.7; P = 0.02). The risk of coronary artery lesion did not differ significantly.

CONCLUSIONS

IVIG treatment by day 4 of illness is associated with the requirement for additional treatment even after adjustment of baseline characteristics. Increased resistance to IVIG when given by day 4 should be considered in order to improve the treatment regimen for early-diagnosed KD.

A Qualitative Assessment of Adolescent Girls' Perception of Living with Congenital Heart Disease: Focusing on Future Pregnancies and Childbirth

PURPOSE

Congenital heart disease (CHD) is the most common birth anomaly in Japan, occurring in approximately 10.6 of every 1,000 live births. Advancements in medical and surgical care have increased births by women diagnosed with CHD. The study's purpose was to examine the perceptions of pregnancy and childbirth among adolescent girls with CHD.

DESIGN AND METHODS

Twelve semi-structured interviews were conducted, and the data were analyzed using a modified grounded-theory approach.

RESULTS

Three categories and 16 subcategories were extracted. Adolescent girls with CHD reported feelings of distress and anxiety while struggling with their disease, and feared how their disease might negatively influence their future pregnancy. These concerns were related to a desire to become familiar with CHD. The girls also explored how their disease would be managed during pregnancy and childbirth. Overall, these perceptions were influenced by the girls' acceptance of their disease, and support from family, friends, and healthcare professionals.

CONCLUSIONS

Healthcare professionals might assess adolescent girls' awareness of their disease before discussing pregnancy and childbirth risks. To encourage them to understand and cope with their disease, healthcare professionals might provide interventions tailored to the timing, stage, and degree of pregnancy and childbirth awareness. This could allow safer life planning, especially concerning pregnancy and childbirth decisions.

PRACTICE IMPLICATIONS

To address adolescent girls' needs, healthcare professionals should continuously assess their awareness of pregnancy and childbirth as well as their psychological status, alongside CHD issues.

Minimally invasive, pericardial implantable cardioverter-defibrillator placement in a young child

We report the successful minimally invasive placement of a pericardial implantable cardioverter-defibrillator (ICD) in a 16-kg child. A transvenous ICD dual coil was advanced through a small subxiphoid incision and screwed into the oblique sinus pericardium under fluoroscopic guidance. An additional sense-pace lead was sutured onto the right ventricular apex, and the generator was placed in the upper abdominal wall through the same incision. Threshold testing demonstrated successful defibrillation at 15 J. After implantation, the patient had two episodes of appropriate shock for ventricular fibrillation. The ICD system continues to show stable impedance at 6 months of follow-up.

Novel Risk Assessment Tool for Immunoglobulin Resistance in Kawasaki Disease: Application Using a Random Forest Classifier

BACKGROUND

Resistance to intravenous immunoglobulin (IVIG) therapy is a risk factor for coronary lesions in patients with Kawasaki disease (KD). Risk-adjusted initial therapy may improve coronary outcome in KD, but identification of high risk patients remains a challenge. This study aimed to develop a new risk assessment tool for IVIG resistance using advanced statistical techniques.

METHODS

Data were retrospectively collected from KD patients receiving IVIG therapy, including demographic characteristics, signs and symptoms of KD and laboratory results. A random forest (RF) classifier, a tree-based machine learning technique, was applied to these data. The correlation between each variable and risk of IVIG resistance was estimated.

RESULTS

Data were obtained from 767 patients with KD, including 170 (22.1%) who were refractory to initial IVIG therapy. The predictive tool based on the RF algorithm had an area under the receiver operating characteristic curve of 0.916, a sensitivity of 79.7% and a specificity of 87.3%. Its misclassification rate in the general patient population was estimated to be 15.5%. RF also identified markers related to IVIG resistance such as abnormal liver markers and percentage neutrophils, displaying relationships between these markers and predicted risk.

CONCLUSIONS

The RF classifier reliably identified KD patients at high risk for IVIG resistance, presenting clinical markers relevant to treatment failure. Evaluation in other patient populations is required to determine whether this risk assessment tool relying on RF has clinical value.

Spontaneous Rotation of Nonlinear Pattern Formed by Aqueous Colloidal Suspension between ITO Electrodes during Electrolysis Perpendicular to Gravity

A colloidal fluid is found to rotate spontaneously during electrolysis when gravity acts perpendicular to the direction of an applied electric field. An aqueous dispersion containing charged colloidal particles is placed inside an O-ring sandwiched between two parallel ITO electrodes. A clip is used to hold the assembly together to prevent the liquid from leaking out. The assembly is positioned such that the electrodes stand vertically, i.e., the electric field during electrolysis points perpendicular to gravity. When a direct-current voltage is applied to initiate the electrolysis of water, a nonlinear colloidal pattern is formed by electroconvective flow. Moreover, the entire fluid rotates spontaneously about the O-ring center with a constant angular velocity. The rotational dynamics are governed by how strong and where the assembly is clipped relative to the gravitational direction. A new phenomenological relationship between the angular velocity, compression vector, and gravity is derived. Coupling of an electrochemical reduction reaction of the ITO film with electroconvection during electrolysis is proposed as a mechanism for the rotational motion.

Genomic Copy-number Aberrations Related to Lymph-node Metastasis of Colon Cancer

Lymph-node metastasis is an important indicator in the diagnosis of colon cancer. In order to determine the genes involved in metastasis, genomic copy-number aberrations in the primary tumours and lymph-node metastases were analysed in 12 patients using comparative genomic hybridization. This method detects genomic copy-number changes at the chromosomal level and the identification of the regions of aberration on any chromosome. Copy-number gains at 6p12 and losses at 8p12 were observed in a greater number of the primary tumours than in the metastases. These aberrations appear to be involved in lymph-node metastasis of colon cancer, and may allow measurement of the risk of lymph-node metastasis from a given colon cancer.

Fever pattern and C-reactive protein predict response to rescue therapy in Kawasaki disease

BACKGROUND

Evidence to guide rescue therapy in refractory Kawasaki disease (KD) is lacking. The aim of this study was to determine the most important variables in predicting non-response to rescue therapy in refractory KD.

METHODS

We retrospectively analyzed 171 patients diagnosed with refractory KD resistant to initial i.v. immunoglobulin (IVIG). Participants received rescue therapy consisting of IVIG monotherapy or IVIG plus prednisolone. Characteristics and laboratory variables were compared between rescue therapy non-responders and responders. Multivariate logistic regression analysis was performed to determine the independent predictors of non-response to rescue therapy.

RESULTS

Among the 171 participants, 54 (31.6%) were non-responders to rescue therapy. On univariate analysis, fever pattern after initial IVIG, day of illness at rescue therapy, rescue therapy regimen and six laboratory variables (pre-IVIG sodium, C-reactive protein [CRP]; post-IVIG white blood cell count, platelet count, sodium, CRP) were useful in discriminating between non-responders and responders. These nine variables were included in multivariate logistic regression analysis. Persistent fever after initial IVIG (aOR, 2.39; 95%CI: 1.07-5.37) and post-IVIG CRP (aOR, 1.09; 95%CI: 1.02-1.17, per 1 mg/dL increase) were identified as independent predictors of non-response to rescue therapy. IVIG rescue monotherapy (aOR, 3.05; 95%CI: 1.05-8.84) also predicted non-response after adjusting for fever pattern and post-IVIG CRP.

CONCLUSIONS

Persistent fever and elevated CRP after initial IVIG are predictive of non-response to rescue therapy for refractory KD. For patients at high risk of non-response, IVIG plus prednisolone, or even further intensified rescue therapy regimens may be preferable.

Central extracorporeal membrane oxygenation requiring pulmonary arterial venting after near-drowning

Extracorporeal membrane oxygenation (ECMO) is an effective respiratory and circulatory support in patients in refractory cardiogenic shock or cardiac arrest. Peripheral ECMO sometimes requires left heart drainage; however, few reports state that pulmonary arterial (PA) venting is required during ECMO support. We present a case of a 14-year-old boy who required PA venting during ECMO support after resuscitation from near-drowning in freshwater. A biventricular assist device with an oxygenator implantation was intended on day 1; however, we were unable to proceed because of increasing of pulmonary vascular resistance from the acute lung injury. Central ECMO with PA venting was then performed. On day 13, central ECMO was converted to biventricular assist device with an oxygenator, which was removed on day 16. This case suggests that PA venting during ECMO support may be necessary in some cases of respiratory and circulatory failure with high pulmonary vascular resistance after near-drowning.

Distinguishing adrenal adenomas from non-adenomas on dynamic enhanced CT: a comparison of 5 and 10 min delays after intravenous contrast medium injection

AIM

To evaluate the usefulness of several parameters of 5 min compared to 10 min delayed contrast-enhanced CT in distinguishing adenomas from non-adenomas.

MATERIALS AND METHODS

The study population consisted of 94 patients (52 men and 42 women; mean age 62 years) with 103 adrenal lesions (75 adenomas and 28 non-adenomas). In each patient, unenhanced CT was followed by early, 5 and 10 min enhanced CT. Diagnostic parameters included delayed enhanced attenuation at 5 and 10 min, washout attenuation (WO) at 5 and 10 min, absolute percentage washout (APW) at 5 and 10 min, and relative percentage washout (RPW) at 5 and 10 min. The accuracy of each parameter for diagnosing adenomas from non-adenomas was calculated using receiver operating characteristic (ROC) analysis.

RESULTS

Upon comparison between 5 and 10 min delayed contrast-enhanced CT for differentiating total adenomas or lipid-poor adenomas from non-adenomas, there was no significant difference in the area under the binomial ROC curve (Az) values of delayed enhanced attenuation (total adenomas versus non-adenomas, p = 0.164; lipid-poor adenomas versus non-adenomas, p = 0.178), WO (total adenomas versus non-adenomas, p = 0.216; lipid-poor adenomas versus non-adenomas, p = 0.230), APW (total adenomas versus non-adenomas, p = 0.401; lipid-poor adenomas versus non-adenomas, p = 0.870), or RPW (total adenomas versus non-adenomas, p = 0.160; lipid-poor adenomas versus non-adenomas, p = 0.780).

CONCLUSION

Five minute contrast-enhanced CT was as useful as 10 min contrast-enhanced CT for differentiation of adrenal adenomas from non-adenomas.

Nizatidine improves clinical symptoms and gastric emptying in patients with functional dyspepsia accompanied by impaired gastric emptying

BACKGROUND/AIMS

In this crossover study, we investigated whether nizatidine, a H(2)-receptor antagonist, can alleviate clinical symptoms and gastric emptying in patients with Rome III-based functional dyspepsia (FD) with or without impaired gastric emptying.

METHODS

We enrolled 30 patients presenting with FD symptoms (epigastric pain syndrome, n = 6; postprandial distress syndrome, n = 24). Rome III-based FD patients were treated with nizatidine (300 mg/day) or placebo for 4 weeks in a crossover trial. Gastric motility was mainly evaluated with the T(max) value using the (13)C-acetate breath test. Meal-related symptoms were defined as postprandial fullness and early satiation. Gastroesophageal symptom was defined as a burning feeling rising from the stomach or lower chest up toward the neck. Acylated- and desacylated ghrelin levels were evaluated by the ELISA method. Clinical symptoms, gastric emptying and ghrelin levels were evaluated at three different points during the study (pretreatment, after 4 weeks former treatment and after 4 weeks later treatment). The primary end point of this study was to determine whether nizatidine would improve clinical symptoms and gastric emptying in FD patients with or without impaired gastric emptying via affecting ghrelin levels.

RESULTS

Meal-related symptoms of the patients treated with nizatidine improved significantly (21/30; 70%) compared to those treated with placebo (3/30; 10%). In addition, nizatidine treatment also significantly improved gastroesophageal symptoms (16/30; 53%) compared to those treated with placebo (0/30; 0%). Nizatidine treatment in patients with FD accompanied by impaired gastric emptying significantly improved clinical symptoms and T(max) value as a marker of gastric emptying (10/11, 91%; 9/11, 82%) compared to placebo therapy, respectively. There were no significant differences in ghrelin levels between nizatidine treatment and placebo therapy.

CONCLUSION

Nizatidine administration significantly improved both gastric emptying and clinical symptoms in FD patients with impaired gastric emptying.