Yasuhiro Ichibori

Usefulness of transient elastography for noninvasive and reliable estimation of right-sided filling pressure in heart failure.

Accurate noninvasive assessment of right atrial pressure (RAP) is important for volume management in patients with heart failure (HF). Transient elastography is a noninvasive and reliable method to assess liver stiffness (LS). We investigated the value of LS for evaluation of RAP in patients with HF without structural liver disease. We measured LS using transient elastography (Fibroscan) in 31 patients undergoing right-sided cardiac catheterization (test group). The relation between LS and RAP found in the test group was used to derive the best-fit model to predict RAP. The applicability of the model was then tested in a validation group of 49 additional patients. There was an excellent correlation between LS and RAP in the test group (r = 0.95, p <0.0001; RAP = -5.8 + 6.7 × ln [LS]). Natural log transformation (ln) of LS provided the regression equation to predict RAP. When the equation model derived from the test group was applied to the validation group, predicted RAP correlated excellently with actual RAP (r = 0.90, p <0.0001). The receiver operating characteristic curve analyses in the test group showed that LS favorably compared with echocardiography for detecting RAP >10 mm Hg (area under the curve 0.958 vs 0.800, respectively, p = 0.047). In the validation group, LS with a cut-off value of 10.6 kPa for identifying RAP >10 mm Hg had a higher sensitivity and accuracy (p = 0.046 and p = 0.049, respectively) than echocardiography. In conclusion, LS may offer an accurate noninvasive diagnostic method to assess RAP in patients with HF.

New Self-Expanding Transcatheter Aortic Valve Device for Transfemoral Implantation – Early Results of the First-in-Asia Implantation of the ACURATE Neo/TF TM System –

BACKGROUND Feasibility and early results of transfemoral aortic valve implantation using the ACURATE neo/TF(TM)self-expanding stent are reported. METHODS AND RESULTS The study group of 15 patients (mean age 83.3±6.0) was enrolled with a mean EuroSCORE and STS score of 21.9±11.6% and 7.5±3.1%, respectively. Clinical and echocardiographic evaluations were performed at baseline, discharge, 30 days and 6 months. The primary endpoint was all-cause mortality at 30 days. Transcatheter aortic valve implantation (TAVI) using the ACURATE neo/TF device was successful in 14 patients; 1 patient underwent valve-in-valve implantation because the prosthetic valve embolized during withdrawal of the delivery system. Conversion to surgery, coronary obstruction, peri-operative stroke, and pacemaker implantation did not occur at 30 days. Mean transvalvular gradients at discharge significantly decreased from 44.2±10.5 mmHg (preprocedural) to 7.7±3.1 mmHg (P<0.0001) and effective orifice area significantly increased from 0.77±0.12 to 1.69±0.25 cm(2)(P<0.0001). None or trace paravalvular leak was revealed in 50.0%, and no patient exhibited moderate or higher paravalvular leak. The overall mortality at 30 days and 6 months was 0% and 6.7%, respectively. CONCLUSIONS A new self-expanding TF TAVI device, ACURATE neo/TF, is safe and effective in the treatment of severe aortic stenosis in elderly patients at high risk for surgery.

Clinical Outcomes and Bioprosthetic Valve Function After Transcatheter Aortic Valve Implantation Under Dual Antiplatelet Therapy vs. Aspirin Alone

BACKGROUND Dual antiplatelet therapy (DAPT) is commonly used after transcatheter aortic valve implantation (TAVI); however, the supporting evidence is limited. To determine if aspirin alone is a better alternative to DAPT, we compared the outcomes of patients treated with DAPT or aspirin alone after TAVI.Methods and Results:We analyzed a total of 144 consecutive patients (92 females, mean age 83±6 years) who underwent implantation of a balloon-expandable transcatheter valve (SAPIEN or SAPIEN XT, Edwards Lifesciences). Patients were divided into DAPT (n=66) or aspirin-alone treatment groups (n=78). At 1 year after TAVI, the composite endpoint, which consisted of all-cause death, myocardial infarction, stroke, and major or life-threatening bleeding complications, occurred significantly less frequently (Kaplan-Meier analysis) in the aspirin-alone group (15.4%) than in the DAPT group (30.3%; P=0.031). Valve function assessed by echocardiography was similar between the 2 treatment groups with respect to effective orifice area (1.78±0.43 cm2in DAPT vs. 1.91±0.46 cm2in aspirin-alone group; P=0.13) and transvalvular pressure gradient (11.1±3.5 mmHg in DAPT vs. 10.3±4.1 mmHg in aspirin-alone group; P=0.31). CONCLUSIONS Treatment with aspirin alone after TAVI had greater safety benefits and was associated with similar valve function as DAPT. These results suggest that treatment with aspirin alone is an acceptable regimen for TAVI patients.

Optical coherence tomography and intravascular ultrasound evaluation of cardiac allograft vasculopathy with and without intimal neovascularization

AIMS Neovascularization is closely associated with plaque progression in non-heart transplantation subjects; on the other hand, cardiac allograft vasculopathy causes unfavourable outcomes. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) can provide microscopic assessment in vivo. The aim of this study was to investigate the impact of neovascularization on intimal proliferation. METHODS AND RESULTS Both IVUS and OCT were attempted in 45 consecutive patients during annual catheterization after heart transplantation. There were 115 vessels [28 vessels were catheterized within 8 weeks of heart transplantation (baseline)]. IVUS analysis assessed vessel, luminal, and intimal (vessel-lumen) volume using Simpsons method. Qualitative parameters including microchannel were assessed by OCT. A microchannel was defined as a no-signal tubuloluminal structure with a sharply delineated border considered to represent neovascularization. Microchannel was observed more often in patient who had their heart transplant more than a year prior to the imaging, compared with shorter periods (39.1 vs. 10.7%, P = 0.023). All microchannels were seen in thickness >0.5 mm, and intimal volume index (mm(3)/mm) correlated with frequency of microchannel (r = 0.54, P = 0.04). The risks for microchannels were donor age [odds ratio (OR) 1.11; 95% confidence interval (CI) 1.03-1.22; P = 0.007], cytomegalovirus infection (OR 16.21; 95% CI 1.79-220.09; P = 0.012), diabetes (OR 9.5; 95% CI 1.21-116.10; P = 0.032), LDL-cholesterol (OR 1.07; 95% CI 1.01-1.13; P = 0.010), and intimal volume (OR 2.47; 95% CI 1.13-6.36; P = 0.023). CONCLUSION OCT-identified microchannels increased sharply within the first year and were correlated with intimal volume and coronary risks. This suggests that neovascularization may play an important role in the progression of cardiac allograft vasculopathy.

Early Outcomes in Japanese Dialysis Patients Treated With Transcatheter Aortic Valve Implantation

BACKGROUND Although transcatheter aortic valve implantation (TAVI) is a new alternative treatment with acceptable midterm results for high surgical risk patients, at present performing the procedure in dialysis patients is not reimbursed in Japan. METHODSANDRESULTS The study group of 17 dialysis patients (mean age, 76.7±5.0 years) underwent TAVI with the SAPIEN/SAPIEN XT. EuroSCORE and STS score were 25.0±19.0% and 15.4±12.3%, respectively. Transiliofemoral and transapical approaches were performed in 7 (41.2%) and 10 patients (58.8%), respectively. ICU and hospital stays after TAVI were 1.8±1.6 and 12.9±12.7 days, respectively. Mean transvalvular gradients at discharge significantly decreased from 45.9±13.3 mmHg to 10.7±4.3 mmHg (P<0.0001) and effective orifice area significantly increased from 0.78±0.17 to 1.69±0.37 cm(2)(P<0.0001). Device success was 87.5%. One patient required a valve-in-valve procedure on 187-postoperative-day for an acute increase in paravalvular leakage caused by initial lower implantation of the device. The overall mortality at 1 year was 0% and clinical efficacies at 30 days, 6 months, and 1 year were 93.8%, 83.3%, and 69.2%, respectively. CONCLUSIONS Satisfactory early results were achieved with TAVI in Japanese dialysis patients with a high surgical risk, indicating it is a safe and effective alternative for the treatment of aortic valve stenosis in such patients.

Cardiac Allograft Vasculopathy Progression Associated With Intraplaque Neovascularization

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 52-year-old man underwent scheduled cardiac catheterization for assessment of cardiac allograft vasculopathy (CAV) at 3 and 12 months after heart transplantation (HTx). Intravascular ultrasound showed

Switching from carvedilol to bisoprolol ameliorates adverse effects in heart failure patients with dizziness or hypotension

BACKGROUND Treatment with carvedilol is an established primary therapy for patients with heart failure (HF). However, its most common adverse effects, dizziness and hypotension, often discourage continuation or dosage increase. The aim of this study was to examine whether switching to bisoprolol from carvedilol would help to avoid adverse symptoms and signs related to carvedilol administration. METHODS AND SUBJECTS Data were retrospectively collected from 23 patients with HF [age 57±18 years, left ventricular ejection fraction (LVEF) 33±15%] who could not increase the dosage of carvedilol because of dizziness or hypotension, defined as systolic blood pressure<90 mmHg. Before and immediately after, and 6 months after switching to bisoprolol, we examined symptoms, vital signs, laboratory data, and New York Heart Association functional class. Furthermore, left ventricular (LV) dimension and ejection fraction (EF) were evaluated in 19 patients using echocardiography. RESULTS All 13 patients with dizziness (100%) and 9 of 16 with hypotension (56%) were relieved of adverse symptoms or signs. The mean dose of carvedilol before switching was 5.60±3.43 mg. Immediately after the switch, the mean dose of bisoprolol was 1.84±1.08 mg and then increased to 3.13±1.74 mg after 6 months (p<0.01). At 6-month follow-up examinations, LV function determined by LVEF was significantly improved, which was accompanied by increased exercise tolerance. CONCLUSION Switching from carvedilol to bisoprolol may help with continuation of β-blocker treatment as well as dosage increase in HF patients with adverse symptoms or signs, allowing them to reach the target dose.

The role of echocardiography in transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is an effective and less invasive treatment for the increasing population of individuals with severe aortic stenosis (AS). Echocardiography is crucial in the assessment of AS patients from pre- to post-procedure. Transthoracic echocardiography (TTE) may be used to assess patient suitability for TAVI, as well as evaluate the severity of AS, the aortic valve complex, aortic valve morphology, mitral regurgitation (MR), and left ventricular function. Transesophageal echocardiography (TEE) is usually used as an intra-procedural monitoring tool to provide feedback during the procedure, to assess prosthetic valve function, and to detect complications rapidly before and after balloon aortic valvuloplasty (BAV) or transcatheter heart valve (THV) deployment. In this review, the role of echocardiography in the pre-, intra-, and post-TAVI procedure periods is described in detail.

EFFECTS OF SWITCHING FROM CARVEDILOL TO BISOPROLOL IN PATIENTS WITH CHRONIC HEART FAILURE

Asrac Caegor: 13. Hear ailure: Therareseaio Numer: 1214-102Auhors: Tatsunori Taniguchi, Yasuhiro Ichibori, Machiko Matsui Kanzaki, Hitoshi Minamiguchi, Isamu Mizote, Tomohito Ohtani, Yoshihiro Asano, Yasushi Sakata, Issei Komuro, Osaka University Graduate School of Medicine, Osaka, JapanBackground: Treame ih careilol has ee esalishe as a rimar hera i aies ih hear failure. Hoeer, aerse smoms or sigs ofe iscourages coiuaio or icreases i osage of his meicaio. We seculae ha sichig o isorolol oul hel aoi aerse smoms a sigs relae o careilol amiisraio.Methods: Daa ere reroseciel collece from 23 aies ih hear failure (age 57±18 ears, NHA 2.±0.7, lef ericular ejecio fracio (LVE) 33±15%) ho coul o icrease heir osage of careilol (5.0±3.43 mg) ecause of aerse smoms (iiess, scoe) or sigs (hoesio: ssolic loo ressure (SB) <90 mmHg). Six mohs afer sichig o isorolol, e chece smoms, ial sigs, laoraor aa a cliical saus (NHA class). urhermore, lef ericular (LV) imesio a coracio ere ealuae i 17 of 23 aies usig echocariograh.Results: All of 13 smomaic aies (100%) a 5 of 10 asmomaic aies (50%) ere reliee of aerse smoms or sigs. The ose of isorolol as icrease from 1.84±1.08 o 3.13±1.74 mg (<0.01). A -moh follo-u examiaios, LV fucio measure LVE as sigiical imroe, accomaie imroeme of exercise olerace.Conclusions: Sichig from careilol o isorolol ma hel ih coiuaio of ʼ-locer reame as ell as osage icrease i aies ih aerse smoms or sigs, alloig hem o reach he arge ose.arameers Baselie mohs alueSB, mmHg 94.1±44.1 109.4±55.1 <0.05HR, m 77.1±38.2 74.±37.2 NSNHA class 2.±1.2 2.4±1.1 <0.05H, mg/l 11.±5.9 12.0±.2 NSCre, mg/l 1.08±0. 1.25±0.78 <0.01BN, g/ml 340.8±417.2 374.9±529.5 NSLVD, mm 59.8±31.5 58.0±31.5 NSLVDs, mm 51.4±27.9 4.2±25.7 <0.01LVE, % 30.3±18.1 39.4±21.8 <0.001