Naoaki Kano

Impact of Renal Functional/Morphological Dynamics on the Calcification of Coronary and Abdominal Arteries in Patients with Chronic Kidney Disease

Aim: Fast-progressing vascular calcification (VC) is accompanied by renal atrophy and functional deterioration along with atherosclerosis in patients with chronic kidney disease (CKD). However, the relationship between VC progression and renal functional and/or morphological changes remains unclear. Methods: We included 70 asymptomatic patients with CKD without hemodialysis in our study. To identify temporal variations, the coronary artery calcification score (CACS), abdominal aortic calcification index (ACI), and renal parenchymal volume index (RPVI) were determined via spiral computed tomography scans taken during the study. We investigated significant factors related to annualized variations of CACS (ΔCACS/y) and ACI (ΔACI/y). Results: During the follow-up period (4.6 years), median values of CACS [in Agatston units (AU)] and ACI increased from 40.2 to 113.3 AU (p = 0.053) and from 13.2 to 21.7% (p = 0.036), respectively. Multivariate analysis revealed that CACS at baseline (p < 0.001) and diabetes mellitus (DM) status (p = 0.037) for ΔCACS/y and ACI at baseline (p = 0.017) and hypertension (HT) status (p = 0.046) for ΔACI/y were significant independent predictors. Furthermore, annualized RPVI variation was significantly related to both ΔCACS/y and ΔACI/y (R = −0.565, p < 0.001, and R = −0.289, p = 0.015, respectively). On the other hand, independent contributions of the estimated glomerular filtration rate (eGFR) and annualized eGFR variation to VC progression were not confirmed. Conclusion: The degree of VC at baseline, DM, HT, and changes in renal volume, but not eGFR, had a strong impact on VC progression in patients with CKD.

Abnormal Circadian Blood Pressure Profile as a Prognostic Marker in Patients with Nonischemic Dilated Cardiomyopathy

Objectives: An abnormal circadian blood pressure (BP) profile is considered a risk factor for cardiovascular disease. However, its significance in heart failure patients with nonischemic etiology is unknown. Herein, we investigated the prognostic value of a circadian BP profile in patients with nonischemic dilated cardiomyopathy (NIDCM). Methods: We enrolled 114 NIDCM patients (76 males, mean age 53.1 years). The percent nighttime BP fall (%NBPF) was defined using ambulatory BP monitoring as a percent decrease in mean systolic BP in nighttime from daytime. All patients were divided into three groups: dipper (%NBPF ≥10), non-dipper (0 ≤ %NBPF < 10), and riser (%NBPF <0). Results: Riser patients had the highest serum creatinine levels (dipper, 0.78 ± 0.20 mg/dl; non-dipper, 0.85 ± 0.21 mg/dl; riser, 0.99 ± 0.23 mg/dl; p = 0.006). In survival analysis, riser patients had the highest cumulative cardiac-related deaths (log-rank, p = 0.001), which was an independent predictor of cardiac-related deaths (hazard ratio, 12.6; 95% confidence interval, 1.76-253; p = 0.01). Multivariate analysis revealed that the norepinephrine level at 24-hour collected urine (24 h U-NE) and the serum creatinine level were independent determinants of %NBPF (adjusted R2 = 0.20; 24 h U-NE, p = 0.0001; serum creatinine, p = 0.04). Conclusions: The riser profile was associated with poor prognosis of NIDCM, which may reflect impaired sympathetic nervous system activity. Evaluating the circadian BP profile may be useful for risk stratification in NIDCM patients.

Intravascular ultrasound-guided percutaneous coronary intervention for total occlusion of the proximal left anterior descending artery caused by spontaneous coronary dissection in a young woman

A 35-year-old woman was admitted to our hospital because of a sudden cardiac arrest caused by an acute anterior myocardial infarction. Emergency coronary angiography showed total occlusion of the proximal left anterior descending artery (LAD). We performed an intravascular ultrasound (IVUS) to detect the LAD orifice and successfully inserted the guidewire to the occluded LAD. An IVUS revealed coronary dissection and no atheromatous plaque from the orifice to the mid-portion of the LAD and the guidewire was in the true lumen. Two bare metal stents were implanted in the proximal and mid portion of the LAD. After stenting to the LAD, coronary dissection retrogradely extended to the left circumflex artery (LCx). Therefore, we performed additional stent implantation from the left main trunk (LMT) to the proximal LCx and the just proximal LAD. An IVUS guided percutaneous coronary intervention (PCI) enabled complete revascularization to spontaneous coronary artery dissection.

Cholesterol metabolism as a prognostic marker in patients with mildly symptomatic nonischemic dilated cardiomyopathy

BACKGROUND Little is known about whether the alteration of cholesterol metabolism reflects abdominal organ impairments due to heart failure. Therefore, we investigated the prognostic value of cholesterol metabolism by evaluating serum campesterol and lathosterol levels in patients with early-stage nonischemic dilated cardiomyopathy (NIDCM). METHODS We enrolled 64 patients with NIDCM (median age 57.5 years, 31% female) with New York Heart Association functional class I/II. Serum campesterol and lathosterol levels were measured in all patients. The patients were then divided into four subsets based on the median non-cholesterol sterol levels (campesterol 3.6μg/mL, lathosterol 1.4μg/mL): reference (R-subset), high-campesterol/high-lathosterol; absorption-reduced (A-subset), low-campesterol/high-lathosterol; synthesis-reduced (S-subset), high-campesterol/low-lathosterol; double-reduced (D-subset), low-campesterol/low-lathosterol. Endpoint was a composite of cardiac events, including cardiac-related death, hospitalization for worsening heart failure, and lethal arrhythmia. RESULTS Median brain natriuretic peptide (BNP) level was 114pg/mL. Mean left ventricular ejection fraction was 31.4%. D-subset had the lowest total cholesterol level and cardiac index and the highest BNP level and pulmonary capillary wedge pressure. D-subset also had the highest cardiac event rate during the mean 3.8 years of follow-up (log-rank p=0.001). Multivariate regression analysis showed that D-subset was an independent determinant of cardiac events. The receiver operating characteristic curve analysis revealed that total cholesterol <153mg/dL was a best cut-off value for discrimination of the D-subset. CONCLUSIONS The combined reduction of campesterol and lathosterol that indicated intestinal cholesterol absorption and liver synthesis predicts future cardiac events in patients with mildly symptomatic NIDCM.

Long-Term Pathological Follow-Up of Myocardium in a Carrier of Duchenne Muscular Dystrophy With Dilated Cardiomyopathy

Duchenne muscular dystrophy (DMD) is a fatal X-linked disorder, with an incidence of ≈1 in 3600 to 6000 male births. DMD is caused by mutations in the dystrophin gene located at Xp21.2 and is clinically characterized by progressive muscle degeneration and dilated cardiomyopathy (DCM). Some female DMD carriers show a variety of clinical manifestations, ranging from creatine kinase elevation to severe muscle weakness. DCM has been reported in 8% to 18% of female DMD carriers and sometimes results in a lethal course. Here, we describe long-term follow-up observations of myocardial changes in a DMD carrier with DCM. A 29-year-old female presented with progressive shortness of breath, increasing ankle edema, and orthopnea after a full-term normal delivery. A chest X ray showed cardiomegaly and bilateral pleural effusions, and echocardiography showed a severely reduced left ventricular ejection fraction of 24%, with a markedly increased left ventricular end-diastolic diameter of 71 mm. She was admitted for heart failure, and her symptoms improved with furosemide and inotropes. There were no symptoms to suggest myopathy, and blood analysis revealed no elevation of creatine kinase (60 U/L). Her newborn boy showed extreme elevation of creatine kinase (105 868 U/L) and was diagnosed with DMD …

Sokolow-Lyon voltage is suitable for monitoring improvement in cardiac function and prognosis of patients with idiopathic dilated cardiomyopathy

The clinical significance of electrocardiogram in the assessment of patients with idiopathic dilated cardiomyopathy (IDCM) is currently unknown. The aim of this study was to determine the feasibility of recording serial changes in Sokolow–Lyon voltage (∆%QRS‐voltage) in one year to estimate left ventricular reverse remodeling (LVRR) and predict a prognosis of IDCM patients under tailored medical therapy.

Associations between proteinuria and cardiovascular risk factors among hypertensive patients in Andkhoy, Afghanistan

ABSTRACT Proteinuria in hypertension is an early marker of renal disease and a predictor for the progression of end stage renal disease, and cardiovascular diseases. This study was designed to determine the prevalence of proteinuria and its association with cardiovascular risk factors among adult hypertensive patients in Afghanistan. Five hundred fifty-five patients with a high blood pressure recorded in an outpatient clinic in Andkhoy, Afghanistan from December 2014 to May 2015, were included in this study. Data obtained from each patient, included demographic characteristics, body mass index, blood pressure patterns, cardiovascular history, cardiovascular risk factors, comorbidity, and current drug-therapy. Dipstick screening for proteinuria was performed with reagent test strips. The mean age of the patients was 57.9 ± 13.3 years, and a female predominance was observed (n = 333, 60%). The prevalence of proteinuria was 67.2%. The predictors of proteinuria were found to be age ≥65 years (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00–1.04), smoking (OR 1.88, 95% CI 1.17–3.02), heart failure (OR 2.23, 95% CI 1.13–4.41), and diabetes mellitus (OR 3.41, 95% CI 1.49–7.81). In conclusion, this study shows that proteinuria is highly prevalent among hypertensive outpatients in an outpatient clinic in Andkhoy, Afghanistan, especially in those with high cardiovascular risk.

Pull-down maneuver of stent graft for abdominal aortic aneurysm with accessory renal arteries

A 78-year-old man admitted to our hospital because of Stanford B type acute thoracic aortic dissection. CT imaging showed abdominal aortic aneurysm (AAA) and bilateral common iliac arterial aneurysms (Fig. 1a, b). He also had bilateral accessory renal arteries (Fig. 1c). The length from the lower accessory renal artery to the terminal aorta was 63 mm. Although his anatomical structure was not suitable for endovascular aortic aneurysm repair (EVAR), we thought it possible to accomplish EVAR, because the length of neck below the lower renal artery was 24 mm and the neck was not so bending, which was enough for sealing neck with stent graft. We performed embolization of internal iliac arteries and EVAR 6 months later. We selected Gore® Excluder® AAA endoprosthesis system, whose length from the top of the stent graft to the end of the contralateral gate is 80 mm. When we deployed the stent graft below the lower accessory renal artery as the conventional method, the contralateral gate would locate in the ipsilateral common iliac artery. On the other hand, if we push up the contralateral gate above the bifurcation, the lower renal arteries would be sacrificed (Fig. 1d). Therefore, we tried to pull down the stent graft once deployed above the renal arteries. We inflated the balloon within the contralateral limb of the stent graft, and constrained the proximal trunk (Fig. 1e). Then, we simultaneously pulled down the main body and the inflated balloon catheter till the top of the stent graft was positioned below the lower renal artery. Final angiography showed the intact lower renal arteries and no endoleak into the aneurysm (Fig. 1f). Accessory renal artery is an anatomical variation found in 28–30% of the general population [1]. The presence of an accessory renal artery arising from the seal zone or aneurysm requires coverage by the stent graft or embolization during EVAR, and it may cause renal function deterioration. Renal infarction occurred only in patients with accessory renal arteries, and 14% of eGFR decreased in 1 week after EVAR, while no renal infarction was observed in patients without accessory renal arteries [2]. When the length of neck below the lower renal artery was enough and the neck was not so bending, we can expect good result of EVAR with pull-down maneuver for patients with accessory renal arteries.

Late-onset Fulminant Myocarditis with Immune Checkpoint Inhibitor Nivolumab

A 60-year-old man was diagnosed with melanoma. After receiving 13 infusions of nivolumab, he had fulminant myocarditis. The myocardial biopsy specimen revealed extensive lymphocytic infiltration, interstitial edema, and myocardial necrosis, with predominant CD4+, CD8+, CD20-, and programmed death-1- markers. Programmed death-1 ligand 1 (PD-L1) was predominantly expressed on the surface of the damaged myocardium. Although it is reported that myocarditis induced by the human anti-programmed death-1 inhibitor nivolumab therapy rarely occurred at > 2 months use in clinical trials, this case showed that even if at a late phase, long-term use of immune checkpoint inhibitors might to lead immune-related adverse events including myocarditis.

The Selvester QRS score as a predictor of cardiac events in nonischemic dilated cardiomyopathy

BACKGROUND Myocardial fibrosis is associated with poor prognosis in nonischemic dilated cardiomyopathy (NIDCM) patients. The Selvester QRS score on 12-lead electrocardiogram is associated with both the amount of myocardial scar and poor prognosis in myocardial infarction patients. However, its use in NIDCM patients is limited. We investigated the prognostic value of the QRS score and its association with collagen volume fraction (CVF) in NIDCM patients. METHODS We enrolled 91 consecutive NIDCM patients (66 men, 53±13 years) without permanent pacemakers or cardiac resynchronization therapy devices. The Selvester QRS score was calculated by two expert cardiologists at NIDCM diagnosis. All patients were followed up over 4.5±3.2 years. Cardiac events were defined as a composite of cardiac death, hospitalization for worsening heart failure, and lethal arrhythmia. We also evaluated CVF using endomyocardial biopsy samples. RESULTS At baseline, the left ventricular ejection fraction was 32±9%, plasma brain natriuretic peptide level was 80 [43-237] pg/mL, and mean Selvester QRS score was 4.1 points. Twenty cardiac events were observed (cardiac death, n=1; hospitalization for worsening heart failure, n=16; lethal arrhythmia, n=3). Cox proportional hazard regression analysis revealed that the Selvester QRS score was an independent determinant of cardiac events (hazard ratio, 1.32; 95% confidence interval, 1.05-1.67; p=0.02). The best cut-off value was determined as 3 points, with 85% sensitivity and 47% specificity (area under the curve, 0.688, p=0.011). In Kaplan-Meier survival analysis, the QRS score ≥3 group had more cardiac events than the QRS score <3 group (log-rank, p=0.007). Further, there was a significant positive correlation of Selvester QRS score with CVF (r=0.46, p<0.001). CONCLUSIONS The Selvester QRS score can predict future cardiac events in NIDCM, reflecting myocardial fibrosis assessed by CVF.