Toshinori Minamishima

Resolution of a warfarin and dabigatran-resistant left atrial appendage thrombus with apixaban.

The majority of embolisms associated with atrial fibrillation (AF) are from the left atrial appendage (LAA). To treat the existing thrombus, warfarin and novel anticoagulants have been used. However, there has been no clinical information regarding the difference of the effects of congealing the fibrinogenolysis system among these oral anticoagulants. Here, we report a case of persistent AF, in whom apixaban, factor Xa inhibitor resolved an LAA clot refractory to warfarin and direct thrombin inhibition. Factor Xa inhibitor, apixaban, could resolve the left appendage thrombosis refractory to warfarin and dabigatran.

Successful Treatment of Severe Right-Sided Heart Failure Due to Postoperative Constrictive Pericarditis With Tolvaptan.

The prognosis of inoperative constrictive pericarditis is poor due to subsequent severe right-sided heart failure that is refractory to conventional medical treatment. This case report describes the long-term treatment with tolvaptan, a new selective vasopression V2-receptor antagonist, was remarkably effective for inoperative constrictive pericarditis. Despite that tolvaptan was approved for the treatment of hyponatremia in Europe and the United States, the indications and treatment duration of it are not yet well established clinically. We propose that tolvaptan could offer an alternative option for the treatment of medically refractory severe right-sided heart failure such as constrictive pericarditis.

Comparison of risk factors for acute worsening renal function in heart failure patients with and without preserved ejection fraction.

OBJECTIVE We compared the risk factors for acute worsening renal function (AWRF) in patients with acute decompensated heart failure with preserved ejection fraction (HFpEF) versus those with reduced ejection fraction (HFrEF). METHODS We retrospectively studied 181 consecutive patients. AWRF was defined as a rise in serum creatinine of ≥0.3 mg/dL from admission to day 3. Potential risk factors of AWRF were identified in univariate analyses; then logistic regression analysis with backward stepwise selection was performed. RESULTS In the present study of limited sample size, 46% had HFpEF (EF≥50%) and 54% had HFrEF (EF<50%). In the HFpEF group, history of hypertension (odds ratio [OR] 32.46, 95% CI 2.39-440.12, P=0.009), the increased serum potassium value at admission (OR 4.61, 95% CI 1.14-18.73, P=0.032), and the pretreatment with calcium channel blocker (OR 8.52, 95% CI 1.21-60.09, P=0.032) were independent risk factors (defined as P<0.05 and OR>1.01) for AWRF. In contrast, diastolic blood pressure at admission (OR 1.07, 95% CI 1.02-1.13, P=0.004) was the sole independent risk factor for AWRF in the HFrEF group. CONCLUSIONS Hypertension was associated with AWRF in both HFpEF and HFrEF patients. A history of hypertension was more important than elevated blood pressure at admission as a risk factor for AWRF in HFpEF, whereas the reverse was observed for HFrEF. Among antihypertensive drugs, pretreatment with calcium channel blocker was an independent risk factor for AWRF in HFpEF, but not in HFrEF.

Considerations in cardio-oncology: Multiple mobile left-sided cardiac thrombi in chemotherapy-induced cardiomyopathy

With advances in cancer chemotherapy, the importance of the new clinical discipline of cardio-oncology, which is concerned with the cardiac effects of chemotherapy, is increasing. Herein we describe the case of a 48-year-old woman with a history of breast cancer who presented with symptoms of heart failure due to chemotherapy-induced cardiomyopathy. Treatment for the patients breast cancer had included surgery and chemotherapy with anthracyclines and trastuzumab. Echocardiography revealed multiple mobile thrombi in the left ventricle and atrium. In addition, brain magnetic resonance imaging revealed small acute cerebral infarctions due to embolization. Given the high risk of re-embolization, surgical thrombectomy was performed. Thus far, there are no standardized therapeutic guidelines for left-sided cardiac thrombi and the optimal treatment remains contentious. Although this patient was managed successfully with surgical thrombectomy, patients should be managed individually, taking into consideration embolization, bleeding, and surgical risks. With further improvements in cancer chemotherapy, there may be an increase in the incidence of complications such as multiple cardiac thrombi. From the cardio-oncology standpoint, we propose close interactions between cardiologists and oncologists for the optimal care of cancer patients.

Differences in predictors of one-year mortality between patients with hypertensive and non-hypertensive acute heart failure: Usefulness of E/E' in hypertensive heart failure.

Multivariate Cox regression analysis with backward stepwise selection was performed with variables showing a statistical value of P b 0.10 in the univariate analyses. Significant risk factors were defined as P b 0.05. BP, blood pressure; CI, confidence interval; E/E′, the ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity; HTNHF, hypertensive heart failure; HR, hazard ratio; nonHTNHF, non-hypertensive heart failure. Differences in predictors of one-year mortality between patients with hypertensive and non-hypertensive acute heart failure: Usefulness of E/E′ in hypertensive heart failure

Bioprosthetic tricuspid valve dysfunction evaluated by real-time three-dimensional transesophageal echocardiography.

A 27-year-old man was referred to our hospital for rightsided heart failure. At the age of 19 years, he had undergone tricuspid valve replacement (TVR) with a bioprosthesis, a Carpentier–Edwards pericardial (CEP) valve, because of infective endocarditis of the tricuspid valve (TV). On examination, he was afebrile, with a blood pressure of 110/66 mmHg and a heart rate of 84 bpm. Auscultation of the heart was notable for a grade 3/6 holosystolic regurgitant murmur and diastolic murmur at the 4th left sternal border. Jugular venous distention and peripheral edema were observed. Dilatation of the right atrium was observed in transthoracic echocardiography and a tricuspid regurgitation (TR) jet was seen on a color Doppler image. Continuouswave Doppler showed a mean pressure gradient of about 12 mmHg across the bioprosthetic TV. Real-time threedimensional transesophageal echocardiography (RT3DTEE) (iE33; Philips, Bothell, WA, USA) was performed in order to evaluate the prosthetic valve function. The RT3DTEE demonstrated tricuspid stenosis with restricted leaflet motion, incomplete closing bioprosthetic TV, and obvious TR (Figs. 1 and 2). The leaflets are thickened and fibrocalcific, with decreased mobility. A redo TVR was performed for valve dysfunction of the CEP. The causes of bioprosthetic valve dysfunction in this case were concluded to be fibrotic and sclerotic degeneration with calcification based on the pathological findings of the extracted bioprosthesis. The RT3D-TEE findings were consistent with these pathological findings.