Haruhisa Ishiguro

Percutaneous Transluminal Pulmonary Angioplasty for the Treatment of Chronic Thromboembolic Pulmonary Hypertension

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

The Full Stomach Test as a Novel Diagnostic Technique for Identifying Patients at Risk of Brugada Syndrome

Introduction: Autonomic modulation, particularly high vagal tone, plays an important role in the occurrence of ventricular tachyarrhythmias in the Brugada syndrome. Food intake modulates vagal activity. We assessed the usefulness of a novel diagnostic technique, the “full stomach test,” for identifying a high‐risk group in patients with a Brugada‐type electrocardiogram (ECG).

Circadian variation of late potentials in idiopathic ventricular fibrillation associated with J waves: Insights into alternative pathophysiology and risk stratification

BACKGROUND The presence of J waves on ECGs is related to idiopathic ventricular fibrillation (VF). OBJECTIVE The purpose of this study was to investigate the pathophysiology of J waves by assessing risk markers that reflect electrophysiologic abnormalities. METHODS The study enrolled 22 idiopathic VF patients (17 men and 5 women; mean age 36 +/- 13 years). Patients were divided into two groups according to the presence or absence of J waves. The following risk stratifiers were assessed: late potentials (LPs; depolarization abnormality marker) for 24 hours using a newly developed signal-averaging system, and T-wave alternans and QT dispersion (repolarization abnormality markers). Frequency-domain heart rate variability (HRV), which reflects autonomic modulation, also was assessed. The results were compared to those of 30 control subjects with J waves and 30 with no J wave, matched for age and gender to the idiopathic VF patients. RESULTS J waves were present in 7 (32%) idiopathic VF patients. The incidence of LP in the idiopathic VF J-wave group was higher than in the idiopathic VF non-J-wave group (86% vs 27%, P = .02). In contrast, repolarization abnormality markers did not differ between the two groups. In the idiopathic VF J-wave group, dynamic changes in LP parameters (fQRS, RMS(40), LAS(40)) were observed and were pronounced at nighttime; this was not the case in the idiopathic VF non-J-wave group and the control J-wave group. High-frequency components (vagal tone index) on frequency-domain HRV analysis were associated with J waves in idiopathic VF patients (P < .05). CONCLUSION Idiopathic VF patients with J waves had a high incidence of LP showing circadian variation with night ascendancy. J waves may be more closely associated with depolarization abnormality and autonomic modulation than with repolarization abnormality.

Pulmonary Edema Predictive Scoring Index (PEPSI), a New Index to Predict Risk of Reperfusion Pulmonary Edema and Improvement of Hemodynamics in Percutaneous Transluminal Pulmonary Angioplasty

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

Time-domain T-wave alternans measured from Holter electrocardiograms predicts cardiac mortality in patients with left ventricular dysfunction: A prospective study

BACKGROUND Time-domain T-wave alternans (TWA) is useful for identifying patients at risk for serious events after myocardial infarction. OBJECTIVE The purpose of this study was to prospectively evaluate the utility of time-domain TWA measured from Holter ECGs in predicting cardiac mortality in patients with left ventricular (LV) dysfunction. METHODS Two hundred ninety-five consecutive patients with LV dysfunction were enrolled in the study. Patients were divided into two groups: the ischemic group (n = 195) and the nonischemic group (n = 100). Time-domain TWA was assessed using the modified moving average method from routine 24-hour Holter ECGs recorded during daily activity. The maximal time-domain TWA voltage at heart rate <or=120 bpm in either lead V(5) or V(1) was derived and its value defined as positive when the voltage was >or=65 microV. The primary end-point was defined as cardiac mortality. RESULTS Mean maximal time-domain TWA voltage was 54 +/- 16 microV. During follow-up of 390 +/- 212 days, 27 patients (17 in the ischemic group and 10 in the nonischemic group) died of cardiac causes. Fifty-three patients (18%) were time-domain TWA positive and 242 (82%) were time-domain TWA negative. Univariate Cox proportional hazards analyses revealed that older age, New York Heart Association functional class III or IV, diabetes, renal dysfunction, nonsustained ventricular tachycardia, and time-domain TWA were associated with cardiac mortality. In multivariate analysis, time-domain TWA had the most significant value (hazard ratio = 17.1, P <.0001). This index also was significant in both subgroups (ischemic group: hazard ratio = 19.0, P <.0001; nonischemic group: hazard ratio = 12.3, P = .002). CONCLUSION Time-domain TWA measured from 24-hour Holter ECGs predicts cardiac mortality in patients with ischemic and nonischemic LV dysfunction.

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

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

Safety and efficacy of percutaneous transluminal pulmonary angioplasty in elderly patients

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

Efficacy of 360-degree three-dimensional rotational pulmonary angiography to guide percutaneous transluminal pulmonary angioplasty

Percutaneous transluminal pulmonary angioplasty (PTPA) is performed with balloon dilatation of the target lesions in the pulmonary arteries through a catheter (Online Figure 1A-Online Figure 1C, Moving image 1, Moving image 2). We routinely perform pulmonary angiography (PAG) using a rotational digital angiography system (Artis zeego multi-axis; Siemens AG, Forchheim, Germany) before the PTPA procedure (Moving image 3). A 360-degree three-dimensional (3D) PAG image is used for identifying the target lesions and estimating their perfusion area easily and rapidly, in addition to identifying the anatomical structures of the pulmonary arteries (Figure 1A, Moving image 4). A rotational 3D PAG image can help us develop therapeutic strategies during PTPA procedures, including guide catheter and balloon size selection. Furthermore, we can visualise the pulmonary artery anatomy in synchronisation with the realtime angiographic view during the procedure, resulting in safe and easy wiring. The rotational 3D PAG image after PTPA is shown in Figure 1B and Moving image 5. Accordingly, this rotational 3D PAG image contributes to the safe and easy performance of PTPA and reduces the amount of contrast agent, leading to a reduction in radiation exposure.

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

Percutaneous coronary intervention (PCI) is safe and effective in very elderly patients, defined as those who are age ≥85 years, with acute coronary syndrome (ACS). However, the prognostic factors remain unknown. The association between activities of daily living (ADL) and the prognosis after PCI has not yet been investigated.

Long-Term Outcomes After Percutaneous Transluminal Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

Therapeutic options for patients with chronic thromboembolic pulmonary hypertension (CTEPH) have expanded significantly with the development of catheter-based interventional therapy, namely percutaneous transluminal pulmonary angioplasty (PTPA) or so-called balloon pulmonary angioplasty (BPA). Conventionally, surgical pulmonary endarterectomy has been the first-line treatment for operable CTEPH. Several teams, including our own, have developed PTPA procedures, and some important reports have been published.1–4 Extrapolating from the published papers, about one third of patients with confirmed CTEPH in Japan have been treated with PTPA over the past decade. It is important to note that according to updated guidelines for the diagnosis and treatment of pulmonary hypertension published in 2016 by the European Society of Cardiology and the European Respiratory Society,5 this catheter-based therapy has been accepted as a therapeutic strategy (Class IIb recommendation for patients with technically inoperable disease or with unfavorable risk-to-benefit ratio for surgery). Because PTPA has only recently been developed, long-term outcomes have not been reported thus far. Therefore, the purpose of the present observational study was to clarify the long-term outcomes for PTPA. The performance of PTPA and analysis of clinical data in the present study were approved by the institutional review boards of Kyorin University Hospital, and all patients …