Tachikawa Medical Center

Previous studies have demonstrated favorable outcomes with percutaneous coronary intervention (PCI) using initial intravascular lithotripsy (IVL) for calcified lesions. However, IVL outcomes under intravascular ultrasound (IVUS) guidance remain unclear. The aim of this study was to evaluate the initial clinical outcomes of PCI for severe calcified lesions using IVUS. In this study, we evaluated initial clinical outcomes of IVUS-guided PCI with IVL for severe calcified lesions. Consecutive IVL cases performed at our hospital between April and October 2023 were retrospectively analyzed. Primary outcomes included cross-sectional area (CSA, mm2) and percent area stenosis (%AS) at the pre-IVL minimum lumen area (MLA) site as measured by IVUS. Pre-IVL, post-IVL, and post-stent results were compared. Secondary outcomes included angiographic success, procedural complications, and major adverse cardiovascular events (MACE) within 1year. Thirty-one patients with 32 lesions were included. CSA values at the pre-IVL MLA site were 2.2 ± 0.9, 4.2 ± 1.5, and 7.5 ± 2.3 mm2, and %AS values were 80.1 ± 7.2%, 62.9 ± 12.3%, and 35.5 ± 16.3% (p < 0.001). Angiographic success was achieved in all cases without complications. At 1year, the cumulative MACE rate was 9.6%, comprising cardiac death (3.2%), myocardial infarction (3.2%), and target vessel revascularization (3.2%). IVUS-guided PCI with IVL for severe calcified lesions demonstrated high procedural success, no complications, and low 1-year MACE rates, highlighting the safety, effectiveness, and clinical relevance of IVUS guidance in real-world practice.

Patient risk factors related to coagulopathy and bleeding when using cefmetazole (CMZ) have not yet been identified, and no models exist to predict side effects during CMZ treatment. Moreover, reports that examine which patients should be careful when using CMZ to ensure safety are lacking. Our objective was to understand risk factors for elevated international normalized ratio (INR) in patients using CMZ and to develop a predictive model for INR elevation using a risk score to enable safe administration of CMZ. This multicenter, retrospective, and observational study was conducted in Tokyo Bay Urayasu Ichikawa Medical Center and Keio University Hospital using data from patients being treated with CMZ. Patients were classified into INR-elevated or non-INR-elevated groups. Univariate and multivariate analyses were performed to calculate the adjusted odds ratios (aOR) and 95% confidence intervals (CI). The actual probability of an elevated INR and probability of an elevated INR predicted by the regression β coefficients were calculated and classified into four categories according to the risk score. Binomial logistic regression analysis revealed that liver disorder (aOR, 5.65; 95% CI, 1.69-18.91; risk scores, 2), nutritional risk (aOR, 6.32; 95% CI, 3.14-12.74; risk scores, 2), no-diabetes mellitus (aOR, 4.53; 95% CI, 1.34-15.26; risk scores, 2), and warfarin use (aOR, 98.44; 95% CI, 7.05-1375.50; risk scores, 5) were significantly associated with INR elevation. The predicted incidence probabilities of INR elevation were < 5% (low risk), 5- < 30% (medium risk), 30- < 90% (high risk), and ≥ 90% (very high risk). The model validity showed a good fit (AUC, 0.79; 95% CI, 0.73-0.85, P < 0.001). We identified risk factors that contribute to INR elevation and constructed a model to predict INR elevation using the risk score. Using this predictive model enables the appropriate use of CMZ in a safe manner.

In recent years, the use of steroids as an initial adjunctive therapy for patients with Kawasaki disease (KD) at high risk of being unresponsive to intravenous immunoglobulin (IVIG) has shown promising outcomes. However, the optimal duration and tapering method of steroid therapy have not been thoroughly investigated. While the Randomized controlled trial to Assess Immunoglobulin plus Steroid Efficacy study, which followed the most prominent protocol in Japan, tapers and discontinues steroids for >15 days, our institution reduces and discontinues steroids over six days once inflammation is adequately controlled. In this study, we aimed to determine the effects of our protocol of steroid tapering in initial combination therapy for KD. The medical records of 359 patients newly diagnosed with KD admitted to our institute between June 2016 and September 2023 were retrospectively reviewed. Among them, 120 patients were classified as being at high risk of IVIG non-response, and 104 patients who met the inclusion criteria were analysed. Of the 104 patients, 23 (22.1%) experienced a recurrence of KD symptoms. Of these, only one patient (1.0% of the total) exhibited symptom recurrence after steroid tapering. One month after the onset of KD, coronary artery lesions were observed in two patients (2.0%), both of whom had small transient coronary artery aneurysms. In cases in which the inflammatory response has been adequately controlled, it may be possible to taper steroid therapy faster than stated in previous studies without compromising treatment outcomes.

Although intraprocedural rupture (IPR) is rare, it is a devastating complication of endovascular treatment (EVT) for intracranial aneurysms. Very few studies have been conducted on IPR, and the safety and efficacy of management techniques of IPR have not been investigated. Patients who experienced IPR during EVT between 2013 and 2022 were enrolled from a multicenter observational registry. We examined the safety and efficacy of the management of IPR using imaging markers, including increased hemorrhage and ischemic lesions, which were evaluated using postoperative computed tomography and diffusion-weighted imaging, respectively. Of the 3269 EVTs for intracranial aneurysms, 74 patients who experienced IPR (2.26%) were analyzed. Fifty-five patients (3.36%) experienced IPR among 1636 EVT cases for ruptured aneurysms. Multivariate analysis revealed that increased hemorrhage was significantly associated with poor outcomes (odds ratio [OR], 6.37 [95% CI, 1.00-40.51], P = .050), whereas ischemic lesions were not. Regarding management techniques of IPR, antihypertensive medication use was significantly associated with increased hemorrhage (OR, 14.16 [95% CI, 2.35-85.34], P = .004). Heparin reversal was an independent factor for ischemic lesions (OR, 8.92 [95% CI, 1.54-51.58], P = .014). Although the setting of IPR may be miscellaneous, and optimal management varies depending on individual cases, heparin reversal might be associated with ischemic complications, and its role in the successful hemostasis in IPR during EVT for ruptured aneurysms remains unclear.

Abstract Romidepsin is an important therapeutic option for patients with peripheral T-cell lymphoma (PTCL). However, the timing of romidepsin administration remains controversial. The objective of this study was to characterize the safety and efficacy of romidepsin as consolidation therapy after gemcitabine, dexamethasone, and cisplatin (GDP) therapy (GDPR). This study of patients treated between March 2019 and March 2021 was registered with the Japan Registry of Clinical Trials (registration number: jRCT0000000519). If complete response, partial response, or stable disease was confirmed after 2–4 GDP cycles, romidepsin was administered every 4 weeks until 1 year. The outcomes of patients participating in this prospective study (PTCL-GDPR) who were receiving GDPR between 2000 and 2015 before starting this trial were retrospectively reviewed. Seven patients with relapsed/refractory (R/R) PTCL [T-follicular helper phenotype (n = 1) and angioimmunoblastic T-cell lymphoma (AITL, n = 6)] were included in PTCL-GDPR. The outcomes of eight patients with R/R PTCL not otherwise specified and seven patients with AITL were retrospectively reviewed. After a median follow-up of 34, 63, and 65 months in patients in PTCL-GDPR and the retrospective cohorts with PTCL-NOS and AITL, respectively, the 2-year OS rates were 71%, 100%, and 100%, respectively, and the overall response rates after treatment were 57%, 100%, and 100%, respectively. Common adverse events in patients in PTCL-GDPR included hematological toxicities such as neutropenia, which improved with supportive treatment. There were no treatment-related mortalities. GDPR might be safe and effective in elderly transplant-ineligible patients with R/R PTCL, and further investigation is warranted.

We aimed to evaluate the mid-term clinical and echocardiographic outcomes of chordal foldoplasty performed for non-resectional mitral valve repair in degenerative mitral valve disease with a large posterior leaflet. We reviewed 82 patients undergoing non-resectional mitral valve repair via chordal foldoplasty between October 2013 and June 2021. We analysed operative outcomes, mid-term survival rate, freedom from reoperation and freedom from recurrent moderate or severe mitral regurgitation (MR). The mean age of patients was 57.2 ± 12.4 years; 61 patients (74%) had posterior leaflet prolapse, 21 patients (26%) had bileaflet prolapse and all of them had at least 1 tall posterior leaflet scallop. Minimally invasive approach with a right mini-thoracotomy was used in 73 patients (89%). The operative mortality was zero. There was no conversion to mitral valve replacement and postoperative echocardiography revealed no more than mild residual regurgitation or systolic anterior motion. Five-year survival rate, freedom from mitral reoperation and freedom from recurrent moderate/severe MR were 93.9%, 97.4% and 94.5%, respectively. Non-resectional chordal foldoplasty is a simple and effective repair technique for select degenerative MR cases with a tall posterior leaflet.

要旨 椎骨動脈狭窄による小脳梗塞によって一過性に視界が上下逆転する現象（reversal of vision metamorphopsia: RVM）を呈した症例を経験した。症例は狭心症，高血圧，糖尿病の既往がある71歳の男性で，浮動性めまいを主訴に救急搬送された。受診2日前と受診前日に突然誘因なく浮動性めまいが出現したが，それぞれ1時間の安静で改善した。受診当日も同様の症状が再燃し悪心も伴うため発症1時間後に救急要請した。来院時のバイタルサインは安定していた。めまいや嘔気の症状が強く可能な範囲での診察では，明らかな脳神経所見の異常はなく運動麻痺や小脳失調も認めなかったが，診察中に患者が「上下が逆に見える」と訴えた。各種画像検査から椎骨動脈狭窄を伴う急性期小脳梗塞と診断し，加療目的に脳神経外科に入院した。入院後にRVMの再燃はなかった。RVMの機序は明らかでないが，本症例では後下小脳動脈領域の梗塞により，視覚と前庭系の情報を統合する前庭小脳繊維が障害されたことが原因と考えた。またRVMの症状は一過性であることが多いとされるが，後頭葉や頭頂葉，残存した正常小脳などが持つ代償機構と，視覚的錯覚からの回復が複合的に機能しているためと考えた。RVMはとくに急性期診療を担う救急外来で遭遇しうるため救急医にとって有用な訴えとなる。RVMを認めた場合は，積極的に中枢性疾患を疑い画像検査を行うべきである。

Endovascular therapy (EVT) is recommended in femoropopliteal (FP) lesions shorter than 25 cm by current guidelines; however, diffuse FP lesions remains challenging for EVT. The aim of this study was to investigate the efficacy of EVT with the latest devices for FP lesions longer than 25 cm. This retrospective multicenter registry analyzed patients presented peripheral artery disease (PAD) having FP lesions longer than 25 cm who underwent EVT using the latest devices between 2017 and 2021. The primary outcome was restenosis 1 year after EVT. The present study enrolled a total of 504 PAD patients with 614 lesions undergoing EVT for diffuse FP lesions. The Kaplan-Meier analysis showed that the rates of freedom from restenosis and clinically-driven target lesion revascularization were 79.3% and 82.4% 1 year after EVT, respectively. The multivariate Cox proportional hazards regression analysis showed that clinical features associated independently with restenosis risk were cilostazol use (adjusted hazard ratio, 0.49 [0.32-0.74]; p = 0.001), reference vessel diameter (RVD) (0.72 [0.58-0.89] per 1-mm increase; p = 0.002), and P3 segment involvement (2.08 [1.33-3.26]; p = 0.001). The Kaplan-Meier analysis was conducted to compare the primary patency between cases with and without a small RVD, P3 involvement, and/or lack of cilostazol; any risk factors were related to a worse primary patency rate, compared with cases without risk factors. In the current EVT era, the primary patency at 1 year was acceptable at 79.3% in patients with FP lesions longer than 25 cm. A small vessel and P3 segment involvement might be associated with a poor 1-year patency rate after EVT, whereas cilostazol administration might contribute to reducing restenosis.