Saiseikai Kumamoto Hospital

Elevated systolic blood pressure (SBP) increases myocardial oxygen demand, whereas low diastolic blood pressure (DBP) can impair coronary perfusion. The prognostic impact of this high-SBP/low-DBP (HSLD) profile in patients with ST-elevation myocardial infarction (STEMI) remains unknown. We analyzed 696 consecutive patients with STEMI undergoing primary percutaneous coronary intervention (PCI) from a prospective 11-center registry in Japan. Patients were categorized based on pre-procedural SBP (≥ 120 mmHg) and DBP (< 70 mmHg) into four groups: high-SBP/low-DBP (HSLD) high-SBP/high-DBP (HSHD), low-SBP/high-DBP (LSHD), and low-SBP/low-DBP (LSLD). The primary endpoint was a 1-year composite of cardiovascular death, non-fatal myocardial infarction, or stroke. Median follow-up was 369 days. The 1-year cumulative incidence of the primary endpoint was 7 (9.5%) in the HSLD group, 19 (4.2%) in the HSHD group, 2 (2.8%) in the LSHD group, and 5 (6.0%) in the LSLD group (log-rank p = 0.007). In multivariable Cox regression, the HSLD was independently associated with the primary endpoint compared to the HSHD group (hazard ratio 3.20, 95% CI 1.04-9.87; p = 0.043). The prognostic value of HSLD was consistent across major subgroups. A pre-procedural blood pressure pattern of SBP ≥ 120 mmHg combined with DBP < 70 mmHg independently predicts a higher risk of adverse cardiovascular events at 1 year in patients with STEMI. This simple measurement at admission identifies a previously unrecognized high-risk phenotype and presents a valuable opportunity for early risk stratification.

Unruptured intracranial aneurysms (UIAs) affect 3.2% of the general population, and approximately 85% of subarachnoid hemorrhages result from their rupture. Despite their classification as low risk by prediction tools such as PHASES (population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, and site of aneurysm) and the Unruptured Cerebral Aneurysm Study (UCAS), UIAs less than 10 mm are susceptible to rupture. To develop and externally validate a machine-learning model (MLM) predicting rupture risk of UIAs. This retrospective multicenter prognostic study analyzed UIAs from 4 institutions across 3 continents from January 2003 to November 2022. Each UIA was characterized by 29 clinical and 18 morphological variables. For model development, patients with UIAs were drawn from a large institutional cohort. Statistical analysis was performed from April 2024 to March 2025. An MLM based on the Light Gradient Boosting Machine algorithm was trained, and performance was assessed for validation externally. The primary outcome was aneurysm rupture within 2 years after risk evaluation. Model performance was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and the area under the receiver operating characteristic curve (AUROC) with 95% CIs. Drawing from 11 579 UIAs from multiple institutions of 8846 patients, there were 2750 patients with 3312 UIAs in the development cohort (median [IQR] age, 65.3 [54.9-73.6] years; 1856 females [67.5%]) and 1153 patients with 1501 UIAs in the external cohort (median [IQR] age, 63.6 [53.9-70.9] years; 828 females [71.8%]), for whom the MLM demonstrated a robust performance in risk estimation. In the development cohort, 71 UIAs (2.1%) ruptured during 8.5 years' median follow-up (IQR, 5.1-11.6 years), and in the external cohort, 48 UIAs (3.2%) ruptured during a median (IQR) follow-up of 5.4 (3.7-8.7) years. With a threshold of 0.52 for the MLM, performance in the development cohort for sensitivity was 0.78 (95% CI, 0.67-0.86); specificity, 0.82 (95% CI, 0.80-0.83); PPV, 0.09 (95% CI, 0.07-0.11); NPV, 0.99 (95% CI, 0.99-1.00); PLR, 4.23 (95% CI, 3.66-4.89); NLR, 0.28 (95% CI, 0.18-0.42); and AUROC, 0.88 (95% CI, 0.85-0.92) and in the external cohort, sensitivity was 0.90 (95% CI, 0.78-0.95); specificity, 0.70 (95% CI, 0.67-0.72); PPV, 0.09 (95% CI, 0.07-0.12); NPV, 1.00 (95% CI, 0.99-1.00); PLR, 2.94 (95% CI, 2.60-3.33); NLR, 0.15 (95% CI, 0.07-0.34); and AUROC, 0.90 (95% CI, 0.85-0.94). The MLM performed consistently in UIAs less than 10 mm (AUROC, 0.88 [95% CI, 0.82-0.94]), suggesting potential complementary value to PHASES and the UCAS. In this prognostic study, the MLM consistently identified features of UIAs as significantly associated with rupture across different cohorts. These results support the MLM's potential to assist physicians and patients in UIA treatment decisions.

Atrial fibrillation (AF) after bioprosthetic valve (BPV) replacement is common in older patients with multiple comorbidities and is associated with a heightened risk of thromboembolism. Anticoagulation therapy is often indicated, but renal impairment and other comorbidities elevate bleeding risk, making clinical decisions complex. This study compared clinical outcomes between warfarin and direct oral anticoagulants (DOACs) in this high-risk population. This subgroup analysis of the BPV-AF Registry included 612 patients treated with oral anticoagulants after BPV replacement, stratified by renal function: normal or mild impairment (creatinine clearance [CCr] ≥50 mL/min), mild-to-moderate impairment (30 mL/min ≤ CCr < 50 mL/min), and moderate-to-severe impairment (15 mL/min ≤ CCr < 30 mL/min). Baseline characteristics and outcomes were analyzed within each stratum. The composite outcome of stroke, systemic embolism, and cardiovascular events was numerically less frequent in the DOAC than warfarin group across all strata, although the differences were not statistically significant. Major bleeding also tended to be lower in the DOAC group. In this study from a Japanese nationwide registry comparing outcomes of AF patients after BPV replacement with severe renal impairment between those treated with DOACs and those treated with warfarin, comparative conclusions between DOACs and warfarin cannot be drawn because of the small sample size. Nonetheless, both anticoagulants may be acceptable in clinical practice, highlighting the need for individualized decision-making based on patient risk.

Abstract Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a critical form of mechanical circulatory support (MCS) for patients with refractory cardiogenic shock (CS). The combination therapy of VA-ECMO and Impella, known as ECPELLA, provides both systemic circulatory support and left ventricular (LV) unloading. However, whether the LV unloading effect of ECPELLA further reduces myocardial damage and mortality in Society for Cardiovascular Angiography and Interventions (SCAI) Stage E patients remains unclear. Objective To evaluate whether ECPELLA reduces myocardial damage and improves short-term survival in refractory CS patients with ST-elevation myocardial infarction (STEMI) requiring VA-ECMO before reperfusion. Methods Between January 2012 and January 2025, we retrospectively screened 239 acute coronary syndrome patients who required advanced mechanical circulatory support (MCS).Patients with non-STEMI, those who did not receive VA-ECMO during percutaneous coronary intervention (PCI) (n=81), and those with mechanical complications, such as left ventricular free wall rupture (n=8) or ventricular septal perforation (n=1), were excluded. Additionally, patients who had absent vital signs after MCS implantation and were deemed for withdrawal of care (n=7) were also excluded from the study. Ultimately, 77 consecutive STEMI patients who received VA-ECMO before reperfusion were included. Patients were divided into two groups: ECPELLA (n=48) and ECMO with IABP (n=28). Serum CK-MB levels and 30-day all-cause mortality were assessed. Results There were no significant differences between the groups in age, sex, coronary risk factors, left main trunk (LMT) lesion, or the rate of extracorporeal cardiopulmonary resuscitation (E-CPR). However, renal impairment (eGFR &amp;lt;60 mL/min/1.73 m²) was significantly more prevalent in the ECMO with IABP group. Additionally, the IABP-SHOCK II score, a prognostic score for CS, was significantly higher in the ECMO with IABP group than in the ECPELLA group (3 [3–4] vs. 4 [3–6]; p=0.015). The ECPELLA group had significantly higher MCS support flow per unit of body surface area during PCI and the first three days, received a significantly lower catecholamine dose, and demonstrated better lactate clearance. ECPELLA also resulted in significantly lower peak CK-MB levels (330 [115–562] IU/L vs. 500 IU/L; p=0.026). Kaplan-Meier analysis demonstrated a significantly higher 30-day survival rate in the ECPELLA group (p=0.003 by log-rank test). Multivariable Cox proportional hazard analysis, adjusting for age, E-CPR, LMT lesion, renal impairment, IABP-SHOCK II score, and ECPELLA, identified ECPELLA as the only independent factor associated with 30-day all-cause mortality (hazard ratio: 0.52, 95% confidence interval: 0.27–0.98; p=0.044). Conclusion ECPELLA treatment provides greater circulatory support and lower CK-MB levels, which may be associated with improved short-term survival compared to ECMO with IABP support.Figure1 Figure2

Introduction: The combination therapy of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and transaortic valve micro-axial flow pump catheter (Impella), so-called ECPELLA, provides powerful hemodynamic support and left ventricular (LV) unloading for cardiogenic shock (CS). However, aortic insufficiency (AI) caused by Impella placement reduces those benefits of ECPELLA. Research Questions: This study investigated the impact of Impella-induced AI on the effects of hemodynamic support and LV unloading by ECPELLA. We examined the relationship between AI severity and regurgitant flow (AI flow) using mock circulation and confirmed the presence of AI-induced hemodynamic deficit in a goat model of ECPELLA. Furthermore, we evaluated the impact of varying AI severity on hemodynamics and LV pressure-volume (PV) loop in ECPELLA circulation by our developed cardiovascular simulation. Methods: In a closed mock circuit with a centrifugal pump, we evaluated the relationship between the AI severity, which was altered by the position of the Impella at the aortic valve (Fig. 1A), and the effective regurgitant orifice area (EROA) estimated from AI flow and pressure gradient. Five Saanen goats (53±2 kg) were used for animal experiments of ECPELLA (Fig. 1B). VA-ECMO flow was set at 1.0, 1.5, and 2.0 L/min. AI flow was calculated from the difference between pulmonary artery and Impella flows. We developed a cardiovascular simulation that employed four cardiac chambers with resistance-compliance networks incorporating ECPELLA (Fig. 1C). Using four AI severity levels, we calculated the hemodynamics and illustrated PV loops by changing Impella CP settings from P0 to P9 under VA-ECMO support. Results: In mock circulation, AI flow increased according to the pressure gradient in each AI severity. Estimated EROA values were 0.018, 0.056, and 0.75 cm 2 for minimal, mild, and severe AI, respectively (Fig. 2A). In goats with ECPELLA, we observed the presence of AI with EROA of 0.18 cm 2 (Fig. 2B). In the simulation, the higher AI severity markedly attenuated the Impella impact on hemodynamic improvement and the leftward and downward shift in PV loop (Fig. 2C). Conclusion: Inappropriate Impella position can cause severe AI. Severe AI substantially reduces both hemodynamic support and LV unloading effects of ECPELLA. Systematic AI assessment is critical for optimal ECPELLA management in CS patients.

Acknowledgements We thank all the local investigators and assistant personnel for their great effort. Furthermore, we thank all the POTTER-AF collaborators.

BACKGROUNDThe Alberta Stroke Program Early Computed Tomography Score and core volume on preoperative imaging are key predictors of clinical outcomes following endovascular therapy in patients with a large ischemic core. Although the corticospinal tract is essential for motor function, its prognostic impact in patients with a large ischemic core remains unclear.METHODSThis multicenter retrospective study analyzed preoperative imaging data from patients with Alberta Stroke Program Early Computed Tomography Score ≤5 who underwent endovascular therapy. The presence of lesions in the posterior corona radiata and lesions in the primary motor cortex was assessed. A good outcome was defined as a modified Rankin Scale score ≤3 at 90 days. The association between lesions in the posterior corona radiata, lesions in the primary motor cortex, and good outcome was analyzed using univariable and stepwise multivariable logistic regression, with variable selection based on Akaike information criterion corrected for small sample size.RESULTSAmong 107 patients, 37 (34.6%) achieved a good outcome. In univariable analysis, neither lesions in the posterior corona radiata nor core volume was significantly associated with a good outcome. In stepwise multivariable logistic regression, modified Rankin Scale score before onset (odds ratio, 0.30 [95% CI, 0.10–0.73]), cardioembolism (odds ratio, 0.25 [95% CI, 0.08–0.76]), absence of lesions in the primary motor cortex involvement (odds ratio, 13.49 [95% CI, 3.75–63.45]), and shorter onset‐to‐reperfusion time (odds ratio, 0.996 [95% CI, 0.992–0.998]) were independent predictors. Alberta Stroke Program Early Computed Tomography Score and the absence of multiple artery occlusion were retained in the final model but were not statistically significant.CONCLUSIONAbsence of lesions in the primary motor cortex involvement was independently associated with good outcome after endovascular therapy in patients with large ischemic core, suggesting its potential utility as a complementary imaging marker in this population.

Chemotherapy-induced neutropenia has been identified as a potential prognostic marker for multiple cancers. However, only one retrospective study, NN-2301, has investigated the relationship between neutropenia and treatment effects of nanoliposomal irinotecan/5-fluorouracil/folinic acid (NFF) in pancreatic cancer. In this prospective study, we aimed to clarify whether NFF-induced neutropenia could serve as a prognostic marker in pancreatic cancer. Data were analyzed from the prospective cohort of the NAPOLEON-2 trial, an observational study involving patients with unresectable pancreatic cancer treated with NFF. Neutropenia severity was categorized into three cutoffs: Cutoff A (Grade [Gr] 0 vs. Gr 1-4), cutoff B (Gr 0-1 vs. Gr 2-4), and Cutoff C (Gr 0-2 vs. Gr 3-4), using the Common Terminology Criteria for Adverse Events version 5.0, owing to conformity with previous studies and simplicity. The primary endpoint was overall survival (OS); progression-free survival (PFS) was the secondary endpoint. The neutropenic groups included Gr 1, 2, 3, and 4, with 79, 23, 34, and 7 patients, respectively. At each cutoff, OS and PFS were significantly better in the severe neutropenia groups. Higher neutropenia grades correlated with improved OS (log-rank trend test: χ2 = 8.62, p < .01). Multivariate Cox regression analysis revealed significant differences for all cutoffs: adjusted hazard ratios were 0.57 (95% confidence interval [CI] 0.40-0.83) (Cutoff A), 0.53 (95% CI 0.36-0.78) (Cutoff B), and 0.52 (95% CI 0.34-0.80) (Cutoff C). NFF-induced neutropenia is a valuable prognostic marker in pancreatic cancer and may guide treatment selection.