Kawasaki Hospital

The mechanisms of luminal narrowing after percutaneous coronary intervention (PCI) with directional coronary atherectomy (DCA) and drug-coated balloon (DCB) remains unclear. This study aimed to investigate the pattern and mechanisms of luminal narrowing after DCA/DCB using optical coherence tomography (OCT). Patients who underwent DCA/DCB for de novo lesions and serial OCT imaging at 3, 6, and 18 months were evaluated to determine the pattern of luminal narrowing. Among 40 patients who had follow-up (F/U) OCT at 3 months post-PCI, 33 and 23 patients had F/U at 6 and 18 months, respectively. Thirty-six of the 40 (90.0%) cases exhibited a layered pattern at the 3-month F/U, 31 of 33 (93.9%) at the 6-month F/U, and 22 of 23 (95.7%) at the 18-month F/U. Layer progression was identified in 21 of 33 (63.6%) and 4 of 23 (17.4%) at the 6- and 18-month F/Us, respectively. The patients with layer progression tended to have a higher prevalence of diabetes (16.7% vs 52.4%, p = 0.067), a lower rate of dual-antithrombotic therapy (DATT) use (58.3% vs 19.0%, p = 0.052) between the 3- and 6-month F/Us, and a significantly higher rate of no or low-intensity statin use (0.0% vs 41.7%, p = 0.037) between the 6- and 18-month F/Us. In Conclusion, layer progression and luminal narrowing occurred mainly during the first 6 months after DCA/DCB. Patients with luminal narrowing tended to have a higher prevalence of diabetes, standard DATT duration, and no or low-intensity statin use.

Background: Atrial fibrillation (AF) is closely linked to endothelial dysfunction, yet its mechanisms remain unclear. Extracellular vesicles (EVs), including exosomes, are released by most cell types and mediate intercellular communication. We therefore investigated the role of EVs in endothelial dysfunction associated with AF. Methods: Vascular endothelial function in patients with sinus rhythm (SR), premature ventricular contractions (PVCs), or AF was assessed by peripheral arterial tonometry. Plasma-derived EVs were isolated from these three groups. Conditioned medium was collected from cultured cardiomyocytes (CMs), which were paced either regularly or irregularly at 1 Hz or 10 Hz or were non-paced, and EVs were subsequently isolated from the conditioned media. The isolated EVs were applied to endothelial cells (ECs), and mRNA levels of vasoactive genes were quantified. Results: The reactive hyperemia index (RHI) was significantly lower in patients with AF than in those with SR (RHI values: 1.98 in SR vs. 1.57 in AF, p = 0.049), whereas no significant decrease was observed in patients with PVCs, indicating endothelial dysfunction in AF. The plasma EV concentration was significantly higher in patients with AF than in those with SR. CMs subjected to 10 Hz irregular pacing released more EVs than non-paced cells and cells under 1 Hz regular pacing. When applied to ECs, EVs from patients with AF and from rapidly paced CMs significantly reduced NOS3 mRNA expression in vitro. Conclusions: Circulating EVs are increased in AF and could be associated with an impaired endothelial function in AF.

Background and Purpose: Pneumonia is a leading cause of death after mechanical thrombectomy (MT) for acute ischemic stroke, alongside stroke-related causes. Early risk assessment of pneumonia-related death could improve management and outcomes. However, risk factors specific to pneumonia-related death remain underexplored, and studies properly accounting for competing risks are limited. We aimed to identify independent predictors and develop a simple predictive index. Methods: We analyzed 3,187 consecutive patients who underwent MT between April 2018 and December 2021 in the K-NET registry, a prospective multicenter registry in comprehensive stroke centers across Kanagawa, Japan. Pneumonia-related death was defined as death from pneumonia within 90 days after stroke onset. It was considered the event of interest, while other causes of death were treated as competing events. Independent predictors were identified using multivariable Fine–Gray competing risk analysis. Based on the identified predictors, we developed a predictive index and evaluated its discriminative ability using bootstrap internal validation. Results: Median age was 78 years, and 45.1% were women. Pneumonia-related death occurred in 83 patients (2.6%), with a median age of 83 years. Independent predictors were male sex (HR 2.85), baseline NIHSS score (HR 1.07), age (HR 1.07), and puncture-to-recanalization time (P2R, HR 1.01). Based on these predictors, we developed a predictive index. The index was calculated as: sex (male: 15, female: 0) + NIHSS + age + 0.1 × P2R (min). The model showed good discrimination, with a C-index of 0.80 and a 90-day time-dependent AUC of 0.81. Conclusions: We developed a simple and accurate predictive index for pneumonia-related death within 90 days after MT. By enabling early identification of high-risk patients and guiding preventive strategies, this index may contribute to improved outcomes and serve as a practical tool in daily stroke care.

Psoriasis is frequently associated with comorbidities such as metabolic syndrome and acute coronary syndrome (ACS). Coronary artery calcification (CAC), an independent predictor of coronary events, has been reported to be more prevalent in psoriasis patients than in healthy controls. However, its clinical significance and relationship with ACS risk in psoriasis remain incompletely understood. We conducted a single-center retrospective cross-sectional study involving 89 Japanese patients with psoriasis who underwent chest computed tomography (CT) to assess the presence of CAC. In selected patients with CAC, coronary CT angiography (CCTA) was performed, and the fractional flow reserve derived from CT (FFRCT) was calculated. Thirty-one patients with CAC were more likely to have psoriasis vulgaris, were older, had lower estimated glomerular filtration rates (eGFR), and exhibited higher hemoglobin A1c (HbA1c) levels compared with those without CAC. Among the 22 patients who underwent CCTA, coronary artery calcium scores (CACS) were positively correlated with Psoriasis Area and Severity Index (PASI) scores, serum C-reactive protein (CRP), and HbA1c levels. FFRCT was measured in 10 patients with ≥ 40% coronary stenosis; six had FFRCT value ≤ 0.80, indicating a high risk of ACS. Multivariable logistic regression analysis using a stepwise selection method identified age as the only significant predictor of ACS risk. In conclusion, elderly psoriasis patients with concomitant diabetes mellitus (DM) may have an elevated risk of ACS and could benefit from cardiology referral for cardiovascular risk assessment.

ObjectivesFamilial hypercholesterolemia (FH) accelerates systemic atherosclerosis and worsens prognosis from youth. While present in 5%–10% of premature coronary artery disease (pCAD) cases, its prevalence and impact in lower extremity artery disease (LEAD) remain unclear. This study investigated FH prevalence and prognostic impact in premature LEAD (pLEAD).MethodsWe retrospectively analyzed LEAD patients aged ≤70 years undergoing first revascularization. FH was diagnosed according to the 2022 Japan Atherosclerosis Society Guidelines, based on dyslipidemia and Achilles tendon thickness. Primary outcomes were survival, amputation-free rate, and secondary intervention-free rate.ResultsAmong 66 pLEAD patients (median age 66 years, 76% male), 10 (15%) met the FH criteria. Compared with non-FH patients, FH patients more frequently presented with chronic limb-threatening ischemia (CLTI) (90% vs. 36%, p = 0.001), bilateral lesions (100% vs. 36%, p <0.001), and dialysis dependence (90% vs. 25%, p <0.001). Three-year survival (28% vs. 90%, p <0.001), amputation-free rate (64% vs. 89%, p = 0.028), and secondary intervention-free rate (38% vs. 63%, p = 0.031) were significantly lower in FH patients. In the CLTI subgroup, survival was markedly reduced in FH (17% vs. 71%, p = 0.011).ConclusionsFH was present in 15% of pLEAD patients and associated with poor outcomes. Routine FH screening, including pCAD history and Achilles tendon evaluation, may improve prognosis.

This study was conducted to compare clinical characteristics and surgical outcomes based on the laterality of diffuse idiopathic skeletal hyperostosis (DISH) with vertebral fracture (VF). We extracted 444 thoracolumbar VF patients in a single center, and 217 patients who underwent balloon kyphoplasty and 159 patients with conservative treatment were excluded. This retrospective study enrolled 68 adult patients who were diagnosed with thoracolumbar VFs that required posterior fusion surgery due to instability. We examined the distribution of DISH on the preoperative whole spine CT images. In particular, we researched the radiographic and clinical characteristics according to the laterality of DISH. We developed a simple grading system (grade 0, no DISH; grade 1, unilateral DISH; grade 2, bilateral DISH≧involving 4 vertebral bodies on both sides). There were 23 DISH patients with VFs, consisting of seven bilateral DISH patients (grade 2) and 16 unilateral DISH patients (grade 1). The ratio of male and lumbar Young Adult Mean index were significantly higher in grade 2 (p < 0.05). The number of contiguous vertebrae was larger in grade 2 than in grade 1 (8.1 ± 3.1 vs. 16.3 ± 2.9, p < 0.001). Among all bilateral DISH patients, DISH extended to the lumbar and was accompanied by other ligamentous unions. The locations of fractured vertebrae in grade 2 were mainly between Th11-L1 (85.7%), and all of them were fractured within the contiguous vertebrae, accompanied by DISH. The present study demonstrated that bilateral DISH was significantly more extensive than unilateral DISH, and the fractured levels of bilateral type were within the contiguous vertebral bodies, accompanied by DISH. On the other hand, there were no differences in surgical outcomes. Our grading system may reflect the radiographic features of DISH with unstable VFs. Further studies with a large number of patients are warranted to provide a better understanding of its validity and reliability. Level of Evidence 2b.

Introduction &amp; Objectives: Upadacitinib (UPA), a selective oral Janus kinase (JAK) inhibitor, and dupilumab (DUPI), a monoclonal antibody targeting interleukin-4Rα, are both treatments approved for patients with moderate-to-severe Atopic Dermatitis (AD). Results from a phase 3b/4 trial (Level Up NCT05601882) indicated that UPA was superior to DUPI in simultaneously achieving the stringent endpoints of Eczema Area and Severity Index (EASI) improvement of ≥90% from baseline (EASI 90) and a Worst Pruritus Numerical Rating Scale score of 0/1 (WP-NRS 0/1) at Week 16. In this post-hoc analysis, we analyzed the median time (days) spent in response states based on EASI 90 and/or WP-NRS 0/1 in patients either receiving UPA or DUPI over a 16-week period. Materials &amp; Methods: The Level Up study was a phase 3b/4 head-to-head global, randomized, open-label, efficacy assessor blinded, multicenter study comparing UPA vs DUPI in adolescents and adults with moderate-to-severe AD. Patients were randomized to UPA 15 mg or DUPI per its label for 16 weeks of treatment. Patients on UPA 15 mg were dose-escalated to 30 mg starting at Week 4 if they had a &lt;EASI 50 response, or a &lt;4-point WP-NRS improvement from baseline. Patients taking UPA 15 mg who did not achieve EASI 75 starting at Week 8 similarly had their dose increased to 30 mg. Starting at Week 4, rescue with topical therapy was optional and per investigator’s discretion if protocol criteria were met. The current analyses assessed the number and proportion of days patients spent with clear or nearly-clear skin (EASI 90) and/or no/minimal itch (WP-NRS 0/1), with comparisons made at the median (50th percentile) and upper quartile (75th percentile). Missing data at study visits were imputed using non-responder imputation with multiple imputations. Results: Participants included 458 patients receiving UPA and 462 receiving DUPI. Cumulatively over a course of 16 weeks, patients taking UPA vs DUPI spent a greater number of days at EASI 90 and WP-NRS 0/1. Over 16 weeks (112 days), 1 in 2 patients (ie, median or 50th-percentile) spent at least 28.0 days at EASI 90 with UPA vs 0 days with DUPI, while 1 in 4 patients spent at least 64.4 days with UPA vs 25.7 days with DUPI. For days at WP-NRS 0/1 with UPA vs DUPI, 1 in 2 patients spent at least 11.3 vs 0.4 days with no/minimal itch respectively; and 1 in 4 patients (ie, upper quartile or 75th-percentile) spent at least 57.2 vs 17.0 days with UPA vs DUPI, respectively. Similar patterns were observed in the number of days simultaneously achieving both EASI 90 and WP-NRS 0/1, as well the proportion of days spent in these responses. Conclusion: Treatment of moderate-to-severe AD with UPA per label resulted in a greater number or proportion of days spent with EASI 90 and/or WP-NRS 0/1 compared with DUPI over 16 weeks. These results highlight differences in lived day- to-day skin disease and itch symptom burden over the course of treatment and can be used to inform shared decision-making discussions between patients and physicians.

Abstract Background Transcatheter aortic valve implantation (TAVI) is a viable alternative to surgery for hemodialysis patients. Purpose This study aimed to compare outcomes of contemporary TAVI in hemodialysis versus non-dialysis patients and stratify all-cause mortality. Methods 336 hemodialysis patients (11.6%) and 2,552 non-dialysis patients (88.4%) undergoing TAVI (2021–2024) were analyzed. The primary endpoint was all-cause mortality, with a median follow-up of 527 days. Results Hemodialysis patients were younger (81 vs. 85 years), mostly male, and had more comorbidities. Thirty-day mortality (2.9% vs. 1.5%) and procedural complications were similar. However, 1- and 2- year all-cause mortality rates were significantly higher in hemodialysis patients (14.4% vs. 6.5%; 21.5% vs. 11.0%, respectively). After adjusting for confounders, the effect of hemodialysis on mortality and composite outcomes disappeared. Independent predictors of mortality in hemodialysis patients included body mass index, Clinical Frailty Scale, and albumin level, enabling risk stratification into low, intermediate, and high-risk groups. Conclusion Among 2,888 patients undergoing TAVI between 2021 and 2024, 11.6% were on hemodialysis. Hemodialysis patients were younger and had more comorbidities with high surgical risk. Thirty-day outcomes, including death and major complications, were similar. While all-cause mortality was significantly higher, comorbidities, not hemodialysis, were the reason for worse outcomes.Abstract picture