Osaka Police Hospital

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018 and updated in 2022 (Ozaki et al. in Cardiovasc Interv Ther 33:178-203, 2018), (Ozaki et al. in Cardiovasc Interv Ther 37:1-34, 2022). Following the publication of the 2023 European Society of Cardiology (ESC) Guidelines for the management of acute coronary syndromes, the CVIT Task Force released another revised version in 2024 (Ozaki et al. in Cardiovasc Interv Ther 39:335-375, 2024). In light of new clinical evidence and technological advances that have emerged since then, the Task Force now proposes an updated expert consensus document for the management of ACS focusing on procedural aspects of primary PCI in 2026 version.

<title>Abstract</title> <bold>Background:</bold> A precise understanding of pelvic anatomy is indispensable for performing pelvic surgery with both safety and oncologic adequacy. Several studies have reported that the internal iliac vein (IIV) exhibits numerous anatomical variations. However, no studies have investigated its venous anatomy using a contrast-enhanced computed tomography (CT) protocol with stricter contrast timing and thinner slice settings. <bold>Methods:</bold> This retrospective study included 106 consecutive patients with rectal cancer who underwent surgery at our institution from 2021 to 2022. All patients underwent contrast-enhanced computed tomography using a protocol optimized for contrast timing and thin-slice reconstruction. The branching patterns of the IIV were evaluated. <bold>Results:</bold> Anomalous branching patterns of the IIV were observed in 44.3% of cases. Multiple IIVs were found in one or both halves of the pelvis. In some cases, the IIV formed communicating channels with the median sacral vein, and in others, a single vein connecting the duplicated inferior vena cava was identified. <bold>Conclusion:</bold> This study demonstrated various anatomical variations of the IIV by using a high-resolution contrast-enhanced CT protocol. These findings improve the understanding of pelvic venous anatomy and provide valuable information that may assist surgeons in preoperative planning and safer performance of pelvic surgery.

Renal function influences the pharmacokinetics of oral anticoagulants in atrial fibrillation (AF), potentially affecting both efficacy and bleeding risk. However, its differential impact across specific agents remains unclear. In this study, we aimed to evaluate the association between renal function and ischemic and bleeding risks in patients with AF, with analyses stratified by anticoagulant type. We analyzed 7239 patients with non-valvular AF from the DIRECT-Extend registry, a pooled dataset of three large-scale registries. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault formula and categorized into ≥50, 30 to <50, and 15 to <30mL/min. The primary ischemic endpoint was stroke or systemic embolism, and the primary bleeding endpoint was major bleeding. Cox proportional hazard models and restricted cubic spline analyses assessed associations between CrCl and outcomes, with subgroup analyses by anticoagulant type. Lower CrCl was associated with older age, female sex, and greater comorbidity burden. Impaired renal function was significantly associated with higher ischemic and bleeding risks. Spline analysis demonstrated a continuous increase in both risks with declining CrCl, with a nonlinear relationship for bleeding. Subgroup analyses revealed significant associations between reduced CrCl and ischemic risk in patients on dabigatran, rivaroxaban, edoxaban, and warfarin. Increased bleeding risk was evident for edoxaban and warfarin at lower CrCl levels. No significant association was observed between CrCl and either endpoint in patients receiving apixaban. In this large real-world cohort, declining renal function was associated with increased ischemic and bleeding risks, highlighting the importance of renal function-based risk assessment in the management of anticoagulation therapy.

BackgroundIdiopathic multicentric Castleman disease (iMCD) remains challenging to treat, with a considerable number of patients showing insufficient response to tocilizumab, the current standard therapy for iMCD. Sirolimus, an mTOR inhibitor, is a potential therapeutic option for tocilizumab-resistant cases based on its mechanism of action and preliminary case reports.MethodsThis investigator-initiated, multicenter, exploratory, placebo-controlled study was designed to evaluate sirolimus (2 mg daily) versus placebo in patients with tocilizumab-resistant iMCD. The primary endpoint was the change in the CHAP (CRP, Hemoglobin, Albumin, Performance Status) score from baseline at week 16. The study was prematurely terminated due to recruitment challenges and the impact of the COVID-19 pandemic, enrolling only two of the planned 20 participants. Both patients completed a 40-week open-label extension phase of sirolimus treatment.ResultsTwo patients were randomized (one sirolimus and one placebo). The primary endpoint of the CHAP score reduction was not achieved during the 16-week double-blind phase. However, the sirolimus-treated patient maintained disease stability (CHAP score remained at 1), whereas the placebo patient experienced disease progression (CHAP score increased from 3 to 5). The secondary outcomes showed contrasting patterns: the sirolimus patient demonstrated improvements in the physician’s global assessment and quality of life measures, while the placebo patient showed deterioration. During the extension phase, the patient initially assigned to placebo experienced significant improvement after switching to sirolimus (CHAP score decreased from 5 to 3, meeting the criteria for a clinically meaningful response). No serious adverse events were reported during the 40-week study period.ConclusionsWhile the study's early termination with only two patients prevents definitive efficacy conclusions, the contrasting disease trajectories between treatment groups and the improvement observed when the placebo patient switched to sirolimus suggest a potential therapeutic benefit. The favorable safety profile of extended sirolimus treatment supports further investigation in larger, adequately powered studies of tocilizumab-resistant iMCD.

We previously reported that IL-33 released during hepatectomy contributes to cytokine-facilitated iCCA tumor growth. However, the underlying mechanisms of the tumor microenvironment remain unexplored. In this study, we aimed to elucidate the impact of IL-33 on cancer-associated fibroblasts (CAFs). The abundance of IL-33-positive cells and alpha-SMA-positive fibroblasts (myoCAFs) was evaluated using resected specimens. Next-generation sequencing (NGS) was performed for comprehensive expression analysis. The effects of IL-33 stimulation on CAFs were investigated in vitro and in vivo using human and murine iCCA cell lines, as well as fibroblasts extracted from resected specimens. IL-33-positive cells and myoCAFs were significant risk factors for intrahepatic recurrence. NGS analysis revealed significant upregulation of various cytokines in cases with high number of IL-33-positive cells. The conditioned medium obtained from fibroblasts stimulated with IL-33 enhanced the proliferation and migration of iCCA cell lines. Among the cytokines that were increased by IL-33 stimulation in vitro, IL-6 was suspected to be the dominant. In a murine syngraft model, hepatectomy led to an increased subcutaneous tumor volume by releasing IL-33, whereas IL-6 blockade suppressed this growth. This study indicated that IL-33 facilitates iCCA growth through fibroblast activation and is associated with intrahepatic recurrence.

Abstract Background Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome rather than a single entity. Left ventricular (LV) remodeling patterns may be associated with this heterogeneity. Population-based studies have shown that LV volume decreases with aging, a key factor for HFpEF development. HFpEF associated with small LV may represent a distinctive phenotype characterized by older age and unique clinical features. Purpose This study aims to investigate the characteristics and clinical outcomes of HFpEF wih small LV. Methods We analyzed 1,140 patients from PURSUIT-HFpEF registry, a multicenter prospective observational registry of acute decompensated HFpEF patients. Clinical data were collected during the compensated phase, after stabilization following acute decompensated HF treatment. The study population was divided into groups with small, normal, and large LV based on LV end-diastolic dimension per the American Society of Echocardiography references. We examined the impact of LV size on all-cause mortality. Results Of 1,140 patients, 161 (14.1%) patients were identified with small LV, and 71 (6.2%) patients were identified with large LV. Patients with small LV were older and had higher heart rates, lower systolic blood pressure, lower body mass index, higher hemoglobin levels, higher estimated glomerular filtration rate, and elevated NT pro-BNP levels. The Kaplan-Meier analysis revealed that LV size was significantly associated with mortality (Log-rank p&amp;lt; 0.001). After adjusting for covariates, small LV remained independently associated with mortality compared with the normal LV group (adjusted hazard ratio: 0.64 [95% confidence interval: 0.49-0.83], p&amp;lt;0.001). Conclusions HFpEF with small LV represents a distinct phenotype characterized by older age, elevated NT-proBNP, fewer comorbidities, and higher mortality. These findings highlight the need for tailored management strategies for this subgroup.

Abstract Introduction Patients with chronic limb-threatening ischemia (CLTI) who achieved wound healing after revascularization often suffer wound recurrence. Previous studies reported that the incidence of wound recurrence within three years ranges from 9 to 17%. Some risk factors have been associated with delayed wound healing in CLTI patients. However, there are limited reports investigating the risk factors of wound recurrence. Purpose The aim of this study was to assess the predictors of wound recurrence after wound healing in CLTI patients. Methods This is the sub-analysis from the SAtellite database of Patients with chronic LImb-threateniNG Ischemia (SAPLING registry), a multicenter retrospective observational study. Present study included 1106 limbs with tissue loss in 877 CLTI patients who underwent endovascular therapy (EVT) and achieved wound healing between April 2010 and March 2023. The primary endpoint was wound recurrence after complete wound healing. Cox proportional hazard model was used to analyze the relationship between patient characteristics and the incidence of primary endpoint. Result The prevalence of hypertension, diabetes mellitus and hemodialysis in the study patients were 69.2%, 64.0%, and 45.7%, respectively. The rate of limbs classified into Rutheford class 6 was 20.7%. The rate of freedom from wound recurrence at one and three years after wound healing was 81.9% and 65.6%, respectively. The median time to wound recurrence after initial wound healing was 498 days. Multivariate analysis revealed the time to wound recurrence was independently associated with hemodialysis (hazard ratio [HR]: 1.82; 95% confidence interval [CI]: 1.39-2.37; p&amp;lt;0.001), non-ambulatory status (HR: 1.41; 95% CI: 1.09-1.84; p=0.009), isolated below-the-knee (BTK) legion (HR: 1.50; 95% CI : 1.16-1.94; p=0.002), higher postoperative ankle-brachial index (ABI) (HR: 0.32; 95% CI : 0.09-0.62; p=0.004), and the Global Limb Anatomic Staging System (GLASS) infrapopliteal (IP) grade 4 (HR: 1.49; 95% CI: 1.01-2.20; p=0.006). Patients were categorized into three groups based on the number of these risk factors: low-risk group (0-1 risk factor), moderate-risk group (2-3 risk factors), and high-risk group (4-5 risk factors). The incidence of wound recurrence increased with a higher number of risk factors. Conclusion Hemodialysis, non-ambulatory status, isolated BTK legion, postoperative ABI &amp;lt;0.90, and GLASS IP grade 4 were identified as independent predictors of wound recurrence in CLTI patients. The risk stratification using these factors may contribute to predict wound recurrence.Freedom from Wound reccurence rate Risk Stratification of Wound reccurence

Enteral nutrition (EN) is often delayed in critically ill cardiovascular patients due to concerns about bowel ischemia, especially when under vasopressor or mechanical support. We evaluated the impact of a structured EN protocol designed to promote timely and safe nutrition delivery in the Cardiac Care Unit (CCU). This single-center retrospective study compared mechanically ventilated CCU patients before (April 2019-March 2020) and after (April 2022-March 2023) protocol implementation. The protocol specified hemodynamic safety thresholds and used a peptide-based formula. Outcomes included EN-related complications, time to EN initiation, and nutritional adequacy within the first week. A total of 116 patients (58 per group) were analyzed. No significant differences were observed in vomiting (P=0.717), diarrhea (P=0.219), or bowel ischemia (P=0.364). The post-protocol group showed a significantly shorter time to EN initiation (median 39.5 vs. 76.0 h; P<0.001). By Day 5, enteral energy adequacy improved (40.8% vs. 12.3%; P<0.001), and protein adequacy increased (62.2% vs. 31.0%; P<0.001). Exploratory analyses showed no significant differences in CCU stay, ventilator-free days, or in-hospital deaths. The EN protocol enabled earlier initiation and improved EN delivery in high-risk CCU patients without increasing complications, offering a safe and practical approach to narrowing the gap between guidelines and practice.

Stent grafts (SGs) are designed to prevent neointimal ingrowth via their expanded polytetrafluoroethylene lining, but restenosis within the stent lumen has been observed in some cases. Here, we report on intra-SG and distal edge stenoses that developed in three patients after SG placement for arteriovenous graft venous anastomotic stenosis. Histopathologic evaluation of the stenoses revealed fibrotic intimal thickening. The intra-SG lesions showed either α-smooth muscle actin-positive spindle cells or chronic fibrotic tissue with hyalinization, and the analyzed distal edge lesion showed α-SMA-positive and partially desmin-positive cells, suggesting myogenic differentiation. To our knowledge, this is the first report to histopathologically confirm intimal tissue formation within the SG lumen. These findings provide histopathologic insight into the spectrum of SG-associated restenosis and suggest that drug-coated balloons, which target intimal hyperplasia, may have therapeutic potential for both intra-SG and distal edge stenoses.