Hiratsuka Kyosai Hospital

Cough reflex and vagal reflex-induced bradycardia are important to predict and prevent prior to PFA to ensure procedural safety and efficacy. However, no studies have yet investigated differences in their incidence among the various PFA systems. We aimed to evaluate the incidence, predictors, and system-specific differences of cough reflex and vagal response during PFA in a large multicenter cohort. Data from 1715 patients undergoing PFA using either PulseSelect, Farapulse, or Varipulse systems at 13 centers were analyzed. Cough reflex was defined as any episode requiring procedure interruption or physical restraint, while a vagal response was defined as sinus arrest or atrioventricular block lasting ≥ 5s. Pulmonary vein isolation was achieved in all patients except for one case. Complications were rare and did not differ significantly among the PFA systems. Cough reflex occurred in 49.3% of patients, most frequently in the left superior pulmonary vein. Compared with Farapulse, the risk of cough reflex was higher with PulseSelect (odds ratio [OR] 1.648, 95% confidence interval [CI] 1.321-2.057) and Varipulse (OR 1.645, 95% CI 1.019-2.657). Patient-related factors such as male sex, asthma, heart failure, and hypertension increased the risk, whereas general anesthesia significantly reduced it (OR 0.236, 95% CI 0.174-0.318). Vagal response occurred in 15.2% of patients, with no significant differences among the PFA systems, and the sequence of pulmonary vein isolation did not affect its occurrence. Prophylactic atropine reduced the risk of vagal response. Cough reflex may vary across PFA systems, while vagal response may remain consistent.

The clinical effectiveness of excimer laser coronary atherectomy (ELCA) in acute coronary syndrome (ACS) remains uncertain due to limited evidence from prior studies. To evaluate the clinical characteristics of patients who underwent primary PCI with ELCA in the setting of ACS, and to asses the impact of ELCA on clinical outcomes. This retrospective study included 586 consecutive ACS patients who underwent primary PCI, stratified by ELCA use (ELCA-group, n = 256; non-ELCA group, n = 330). Propensity score matching was performed to compare clinical outcomes between the groups. The primary endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiac death, nonfatal myocardial infarction, and target lesion revascularization (TLR). Subgroup analysis was conducted to identify factors associated with the efficacy of ELCA. Patients in the ELCA group were younger, more often presented with STEMI, had lower initial TIMI flow grades, and exhibited a higher thrombus burden with less calcification compared to the non-ELCA group. After propensity score matching, baseline characteristics were well balanced. MACE occurred in 6% of the ELCA group and 15% of the non-ELCA group (p = 0.001), with this difference remaining significant after matching (p = 0.001). The difference in MACE was primarily driven by the rate of TLR (3% vs. 10%, p < 0.001), which also remained significant after matching (p < 0.001). Slow flow occurred in 26% of the ELCA group and 19% of the non-ELCA group; however, the difference disappeared after matching (p = 0.526). Rates of perforation and distal embolization were low, with no significant difference between groups. Subgroup analysis revealed that initial high TIMI flow grade (TIMI 2 or 3), diabetes mellitus (DM), and hypertension were significantly associated with improved outcomes from ELCA. In ACS, ELCA was selectively performed in those with specific clinical and lesion characteristics and was associated with reduced MACE in real-world practice. Subgroup analysis suggested that patients with initial high TIMI flow grade, DM, and hypertension might derive greater benefits from ELCA. These findings highlight the importance of lesion selection in optimizing the safety and effectiveness of ELCA in ACS.

Five-year outcomes from the two major trials indicated higher mortality with instantaneous wave-free ratio (iFR)-guided revascularization compared to fractional flow reserve (FFR)-guidance, despite similar outcomes in deferred patients. This discrepancy likely comes from discordant revascularization decisions. To precisely assess the characteristic differences, including microvascular function, between resting full-cycle ratio (RFR)-guided and FFR-guided strategies, we performed virtual randomization, specially targeting discordant lesions, to simulate RFR-guided and FFR-guided groups. Microvascular resistance reserve (MRR) was utilized to assess microvascular function independently of epicardial stenosis. We retrospectively analyzed 837 intermediate lesions in 620 patients, from our institutional physiological database, with a median follow-up of 6.9 years. Using thresholds of FFR ≤ 0.80 and RFR ≤ 0.89, lesions were categorized into concordant-high (n = 280), high-RFR/low-FFR (n = 105), low-RFR/high-FFR (n = 93), and concordant-low (n = 359) groups. Discordant and concordant lesions were virtually randomized into RFR- and FFR-guided groups. Patients were followed for 6.9 (4.6-9.1) years. Age, sex, percentage diameter stenosis, and MRR differed significantly between the RFR/FFR discordant groups. After randomization, no significant characteristic-based differences were observed between both concordant and discordant virtual RFR/FFR-guided groups. Compared with the patients with FFR-guided would-be-revascularized lesions, those with RFR-guided would-be-revascularized lesions with discordant RFR/FFR results had significantly lower MRR, higher age, and tended to be female. MRR significantly predicted all-cause death in the total and would-be-revascularized cohorts, but not in deferred patients. In discordant lesions of virtually randomized RFR- and FFR-guided strategies, RFR-guided would-be-revascularized lesions were associated with impaired microvascular function (low MRR) compared with FFR-guided would-be-revascularized lesions, which may underlie the reported increased mortality in iFR-guided revascularized patients.

Abstract Backgrounds Previous studies have demonstrated potential effect of excimer laser coronary atherectomy (ELCA) to reduce thrombus burden within the vessel, and ELCA has been used during primary PCI for acute coronary syndrome. Especially, the culprit lesions of ST-segment elevation myocardial infarction (STEMI) are generally accompanied by large thrombus burden. Nevertheless, the clinical effectiveness of ELCA use for the culprit lesions of STEMI has not been elucidated. Purpose To investigate the clinical outcomes of the STEMI patients who were treated with ELCA during primary PCI in comparison with those treated without ELCA. Methods We conducted the registry study of STEMI for the assessment of the efficacy of ELCA, which was an observational multicenter registry of the consecutive patients undergoing primary PCI for STEMI within 24 hours from the onset between 2015 and 2019. The patients were divided into two groups according to the use of ELCA during primary PCI: ELCA group and non-ELCA group. The primary endpoint was the major adverse cardiovascular event (MACE), which was defined as the composite of cardiovascular death (CVD), target vascular revascularization and non-fatal AMI. Propensity score (PS) matching was performed to adjust the bias of confounding factors using 1:1 nearest-neighbor matching without replacement. PS was yielded from clinical characteristics, baseline angiographic findings, and hemodynamic status that were imbalanced between the two groups. Results A total of 2593 patients, 424 patients in ELCA group and 2169 patients in non-ELCA group, were included in the analysis. PS matched cohort comprised 824 patients including 412 ELCA and 412 non-ELCA group. Median follow-up duration in the total cohort was 816 (394-1388) days. In the total cohort, baseline characteristics showed that younger age, less prevalent hypertension, and more frequent prior statin use in ELCA group than in non-ELCA group. In terms of clinical outcomes, ELCA group showed a significantly lower rate of CVD than non-ELCA group (4.3% vs 7.5%, P for log-rank = 0.03), whereas MACE rate was similar between the two groups (HR:1.00 95%CI 0.74-1.34, P=0.99). In the PS matched cohort, the baseline characteristics were well balanced. Clinical outcomes including MACE and CVD were comparable between the two groups (MACE HR:1.13 95%CI 0.76-1.66, P=0.53 and CVD HR0.70 95%CI 0.38-1.29 P=0.25). In the subgroup analysis, MACE rate was lower in ELCA group than in non-ELCA group in the patients who presented with Killip class III or IV (P for interaction &amp;lt;0.01) (Abstract Picture 1). Conclusions The use of ELCA was not associated with improved MACEs in both total cohort and the PS matched cohort, whereas subgroup analysis suggested a potential benefit of ELCA in patients with heart failure. Further prospective investigations are warranted.Forest Plots for Subgroup Analysis

The prognosis of anaplastic thyroid carcinoma (ATC) is poor, and there is currently no established treatment to improve its outcome. We previously reported that enhancer of zeste homolog 2 (EZH2) was highly expressed in ATC, and may be a therapeutic target; however, the effects of EZH2 on ATC growth currently remain unknown. We investigated the effects of an EZH2 inhibitor (DZNep) on four ATC cell lines (8305C, KTA1, TTA1 and TTA2). We performed a gene panel analysis of all ATC cell lines to identify differences in DZNep sensitivity between the cell lines. To investigate the effects of DZNep on the recovery of differentiation, we assessed changes in thyroid differentiation markers (TDMs) before and after the DZNep treatment using PCR. EZH2 was expressed in all ATC cell lines. The cell-reducing effects of DZNep were detected in all ATC cell lines, and were the strongest in KTA1 cells followed by TTA2 cells. The TTA1 and 8305C cell lines, which showed weak cell-reducing effects, had TP53 mutations. No changes in TDMs were observed in any ATC cell line. DZNep, an EZH2 inhibitor, exerted suppressive effects on the growth of ATC cell lines and has potential as a therapeutic strategy; however, its effects may be attenuated in ATC with TP53 mutations.

A 73-year-old woman with silent cardiac metastasis underwent high anterior resection for rectal cancer 3 years ago. Follow-up computed tomography showed a tumor in the right atrium. Partial vascular resection of the superior vena cava and right atrium was performed. Early postoperative recurrence occurred, and chemotherapy was unsuccessful. The patient died 7 months after surgery.

BackgroundDiffuse pulmonary ossification is a specific lung condition that is accompanied by underlying diseases. However, idiopathic dendriform pulmonary ossification (IDPO) is extremely rare, and the clinical features remain unclear. In this study, we aimed to report the clinical characteristics of IDPO.MethodsWe conducted a nationwide survey of patients with IDPO from 2017 to 2019 in Japan and evaluated the clinical, radiological, and histopathological findings of patients diagnosed with IDPO.ResultsTwenty-two cases of IDPO were identified. Most subjects (82%) were male, aged 22–56 years (mean (SD), 37.9 (9.1)) at diagnosis. Nearly 80% of the subjects were asymptomatic, and the condition was discovered during a medical check-up. However, 36% of the subjects showed a decline in forced vital capacity (%FVC) predicted <80% at diagnosis. The typical radiological features of high-resolution CT (HRCT) are calcified branching structures that are predominantly distributed in the lower lung fields without any other conspicuous finding. Histopathological analysis also showed dendriform ossified lesions from the intraluminal areas to interstitial areas. Notably, during the follow-up period of 20 years, disease progression was found in 88% on HRCT and more than 50% on pulmonary function tests (FVC and/or forced expiratory volume in 1 s). Two cases with rapid decline of 10% /year in %FVC predicted were observed.)) at diagnosis. Nearly 80% of the subjects were asymptomatic, and the condition was discovered during a medical check-up. However, 36% of the subjects showed a decline in forced vital capacity (%FVC) predicted <80% at diagnosis. The typical radiological features of high-resolution CT (HRCT) are calcified branching structures that are predominantly distributed in the lower lung fields without any other conspicuous finding. Histopathological analysis also showed dendriform ossified lesions from the intraluminal areas to interstitial areas. Notably, during the follow-up period of 20 years, disease progression was found in 88% on HRCT and more than 50% on pulmonary function tests (FVC and/or forced expiratory volume in 1 s). Two cases with rapid decline of 10% /year in %FVC predicted were observed.ConclusionsIDPO develops at a young age with gradually progressive phenotype. Further research and long-term (>20 years) follow-up are required to clarify the pathogenesis and clinical findings in IDPO.