Hironobu Toda

Clinical characteristics of responders to treatment with tolvaptan in patients with acute decompensated heart failure: Importance of preserved kidney size

BACKGROUND Recent clinical trials have demonstrated the efficacy of short-term treatment with tolvaptan, an oral vasopressin V2 receptor antagonist, in patients with heart failure. However, the response to tolvaptan varies among patients. The aim of this study was to determine factors associated with response to tolvaptan in patients with acute decompensated heart failure (ADHF). METHODS The Tolvaptan Registry, a prospective, observational, multicenter cohort study performed in Japan, aims to determine factors affecting the responsiveness of tolvaptan in patients with ADHF. We enrolled ADHF patients treated with tolvaptan and they were divided into two groups: responders and non-responders. Responders were defined as subjects who met all of the following three conditions: (1) increasing urine volume during a 24-hour period after the start of tolvaptan treatment; (2) improvement in New York Heart Association functional class; and (3) decrease in cardiothoracic ratio assessed by chest X-ray on day 3 of tolvaptan administration. RESULTS Among the 114 patients, treatment with tolvaptan improved three conditions of heart failure in more than half of all the cohorts (71 patients, 62%). As for baseline characteristics, estimated glomerular filtration rate, urine osmolality, and kidney size were significantly greater in responders than in non-responders. Multivariate logistic analysis revealed that kidney size was independently associated with responders (odds ratio: 1.083, p=0.001, 95% confidence interval 1.031-1.137). CONCLUSIONS The main clinical characteristic of responders to treatment with tolvaptan is that kidney size is preserved.

Dual Antiplatelet Therapy Can Be Discontinued at Three Months after Implantation of Zotarolimus-Eluting Stent in Patients with Coronary Artery Disease

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention increases the risk of bleeding. We studied the safety and clinical outcomes of switching from DAPT to aspirin monotherapy at 3 months after ZES implantation. We retrospectively evaluated 168 consecutive patients with coronary artery disease who had been implanted with a ZES from June 2009 through March 2010. After excluding 40 patients according to exclusion criteria such as myocardial infarction, 128 patients were divided into a 3-month DAPT group (67 patients, 88 lesions) and a 12-month conventional DAPT group (61 patients, 81 lesions). Coronary angiographic followup and clinical followup were conducted at more than 8 months and at 12 months after ZES implantation, respectively. Minor and major bleeding events, stent thrombosis (ST), and major adverse cardiac events (MACE) (death, myocardial infarction, cerebrovascular accident, target lesion revascularization, and target vessel revascularization) were evaluated. There were no statistically significant differences in the incidences of ST and MACE between the two groups. The incidence of bleeding events was significantly lower in the 3-month group than in the 12-month group (1.5% versus 11.5%, P < 0.05). DAPT can be safely discontinued at 3 months after ZES implantation, which reduces bleeding risk.

Diastolic Dysfunction Is a Risk of Perioperative Myocardial Injury Assessed by High-Sensitivity Cardiac Troponin T in Elderly Patients Undergoing Non-Cardiac Surgery

BACKGROUND High-sensitivity cardiac troponin T (hs-cTnT) is useful for detecting myocardial injury and is expected to become a prognostic marker in patients undergoing non-cardiac surgery. The aim of this pilot study evaluating the efficacy of β-blocker therapy in a perioperative setting (MAMACARI study) was to assess perioperative myocardial injury (PMI) in elderly patients with preserved ejection fraction (EF) undergoing non-cardiac surgery.Methods and Results:In this prospective observational cohort study of 151 consecutive patients with preserved EF and aged >60 years who underwent non-cardiac surgery, serum levels of hs-cTnT were measured before and on postoperative days 1 and 3 after surgery. PMI was defined as postoperative hs-cTnT >0.014 ng/mL and relative hs-cTnT change ≥20%. A total of 36 (23.8%) of the patients were diagnosed as having PMI. The incidence of a composite of cardiovascular events within 30 days after surgery, including myocardial infarction, stroke, worsening heart failure, atrial fibrillation and pulmonary embolism, was significantly higher in patients with PMI than in patients without PMI (odds ratio (OR) 9.25, P<0.001, 95% confidence interval (CI) 2.65-32.3). Multivariate analysis revealed that left ventricular diastolic dysfunction defined by echocardiography was independently associated with PMI (OR: 3.029, 95% CI: 1.341-6.84, P=0.008). CONCLUSIONS PMI is frequently observed in elderly patients undergoing non-cardiac surgery. Diastolic dysfunction is an independent predictor of PMI.

Catheter ablation of three macroreentrant atrial tachycardias after surgical repair of Double-Outlet Right Ventricle

A 54‐year‐old man with a surgically repaired double‐outlet right ventricle (DORV) presented with palpitations and worsening right heart failure. His 12‐lead ECG showed atrial tachycardia (AT) with an atrial cycle length (CL) of 300 ms and an inverted saw‐tooth F‐wave pattern in the inferior leads II, III, and aVF typical of atrial flutter. Electrophysiological study and radiofrequency catheter ablation were performed. A total of 3 sustained ATs (AT1–AT3) were induced. Using the electroanatomical mapping system, CARTO3, and conventional mapping techniques, the ATs were identified as macroreentrant tachycardias circling around an incisional line on the free wall of the right atrium (AT1), the tricuspid annulus (AT2), and low voltage area in the lateral wall including the right septum (AT3). Accuracy of CARTO3 in three‐dimensional reconstruction was sufficient to elucidate anatomical features (including catheter sites, incision, and low voltage areas) and macroreentrant circuits. However, conventional mapping techniques were also necessary to identify the mechanism of the tachycardias, and therefore to eliminate all of them successfully. This case demonstrates that the use of combined conventional and electroanatomical mapping techniques, such as CARTO3, can be helpful in identifying the critical isthmus for catheter ablation of macroreentrant AT in patients with surgically corrected congenital heart disease (CHD).

The Number of Leads of Abnormal Q Waves is a Predictive Factor for Aggravation of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy is generally considered to be a good prognosis disease ending up as transient cardiac hypofunction,but some cases such as severe cardiac failure,cardiogenic shock,and cardiac rupture become serious. We investigated cases of Takotsubo cardiomyopathy in our hospital, and evaluated predictive factors for aggravation of the disease.We retrospectively evaluated the clinical data of 38 patients ! 7 males and 30 females; their mean age, 74.0 O who had been diagnosed with Takotsubo cardiomyopathy between May 2004 and November 2009. The patients were divided into a severe group ! patients with any of 1.cardiac arrest, 2.concomitant cardiogenic shock ! patients treated with catecholamine and iabp/pcps O, 3. severe congestive cardiac failure needing mechanical ventilation, and 4.mechanical complications ! cardiac rupture and cardiac tamponade O and a mild group ! patients with remission after conservative treatment O, and the patients’ backgrounds, vital signs at diagnosis, electrocardiographic indexes,and blood examination values were followed up.The number of leads of abnormal Q waves seen on electrocardiograms at the time of diagnosis was significantly larger in the severe group than in the mild group.The number of leads of abnormal Q waves appearing at the time of occurrence of Takotsubo cardiomyopathy or during its course is likely to become a predictive factor for aggravation of the disease.