Toyohashi Heart Center

For patients with atrial fibrillation, the use of oral anticoagulant therapy to prevent stroke is limited by the risk of bleeding. Left atrial appendage closure is considered for patients who are unsuitable candidates for long-term anticoagulation, but its role in patients who are eligible for anticoagulants has not been established. In this ongoing, prospective, international, randomized trial involving patients with atrial fibrillation who were suitable candidates for anticoagulation, we randomly assigned patients in a 1:1 ratio to receive either device-based left atrial appendage closure (device group) or non-vitamin K antagonist oral anticoagulant (NOAC) therapy (anticoagulation group). The primary efficacy end point - a composite of death from cardiovascular causes, stroke, or systemic embolism - was tested for noninferiority (noninferiority margin, 4.8 percentage points) after 3 years of follow-up. The primary safety end point, non-procedure-relatedbleeding, was tested for superiority. Of the 3000 patients who underwent randomization, 1499 were assigned to the device group and 1501 to the anticoagulation group. The mean (±SD) age of the patients was 71.7±7.5 years, 31.9% of the patients were women, and the mean CHA2DS2-VASc score was 3.5±1.3. At 3 years, a primary efficacy end-point event had occurred in 81 patients (Kaplan-Meier estimate, 5.7%) in the device group and in 65 patients (Kaplan-Meier estimate, 4.8%) in the anticoagulation group (difference, 0.9 percentage points; 95% confidence interval [CI], -0.8 to 2.6; P<0.001 for noninferiority). Non-procedure-related bleeding occurred in 154 patients (Kaplan-Meier estimate, 10.9%) in the device group and in 260 patients (Kaplan-Meier estimate, 19.0%) in the anticoagulation group (hazard ratio, 0.55; 95% CI, 0.45 to 0.67; P<0.001 for superiority). Among patients with atrial fibrillation who were candidates for anticoagulation, device-based left atrial appendage closure was noninferior to NOAC therapy with respect to a composite of death from cardiovascular causes, stroke, or systemic embolism and was superior to NOAC therapy for non-procedure-related bleeding at 3 years. (Funded by Boston Scientific; CHAMPION-AF ClinicalTrials.gov number, NCT04394546.).

Abstract The Darwin wasp Neotypus coreensis Uchida, 1930 (Ichneumonidae: Ichneumoninae) is rediscovered. A female was reared from a pupa of the endangered lycaenid Niphanda fusca (Bremer &amp; Grey, 1853) collected in Oita Prefecture, Kyushu. This represents the first confirmed record of this species from Japan since the records reported by Hirukawa (1985) and the first record from Kyushu. DNA barcoding (658 bp of mt COI ) confirmed the identification and showed close similarity to Neotypus melanocephalus . Although the Japanese and European populations of N. coreensis are morphologically identical, they parasitize different hosts: Niphanda in Japan and Maculinea in Europe. The rediscovery highlights the importance of parasitoids in understanding and conserving endangered insect–parasite interactions.

The management of very low-gradient (LG) severe aortic stenosis (AS) remains challenging. Moreover, limited evidence exists regarding the outcomes of patients with very LG severe AS following transcatheter aortic valve implantation (TAVI). Weaimedto elucidate the prognosis of patients with very LG severe AS after TAVI and the influence of flow status. Data were retrospectively collected from the OCEAN-TAVI multicenter registry in Japan, including patients with severe AS who underwent TAVI. In total, 7103 patients were classified into three groups based on their baseline mean pressure gradient (MPG): very LG (MPG ≤ 20 mmHg), LG (20 < MPG < 40 mmHg), and high-gradient (HG) (MPG ≥ 40 mmHg). The primary endpoint was a composite of all-cause mortality and hospitalization for heart failure. During a median follow-up period of 741 days, the composite endpoint was reached in 2081 patients. Patients with very LG severe AS had a higher prevalence of comorbidities. Kaplan-Meier analysis showed that very LG severe AS was associated with significantly lower event-free survival compared to that with LG and HG severe AS. Multivariable Cox regression analysis identified very LG severe AS as an independent poor prognostic indicator, regardless of the flow state. Moreover, within the very LG severe AS group, a low body mass index and myocardial infarction history were associated with worse outcomes. This study indicates that patients with very LG severe AS have worse prognoses compared to those with LG or HG severe AS following TAVI, regardless of the flow state.

BackgroundComparative data on early- (G2) vs newer-generation (G4) MitraClip transcatheter edge-to-edge repair (TEER) systems remain limited.ObjectivesThe authors compared procedural and clinical outcomes of both devices in patients with degenerative mitral regurgitation (DMR) or functional mitral regurgitation (FMR).MethodsUsing the OCEAN (Optimized Catheter Valvular Intervention)-Mitral registry, 3,738 patients undergoing TEER with either G2 (n = 1,481) or G4 (n = 2,257) MitraClips were analyzed. Outcomes included procedural metrics, echocardiographic parameters, and clinical events.ResultsDespite being older (P = 0.010) and higher-risk (EuroSCORE [European System for Cardiac Operative Risk Evaluation] II: P = 0.002), the newer-generation group achieved comparable procedural success (residual MR ≤2+) with shorter procedure time and fewer clips, resulting in significantly lower transmitral mean pressure gradients (TMPG) (DMR: median: 3.0 [Q1-Q3: 2.0-4.0] mm Hg vs 2.7 [Q1-Q3: 2.0-3.8] mm Hg; P = 0.009; FMR: median 3.0 [Q1-Q3: 2.0-4.0] mm Hg vs 2.5 [Q1-Q3: 1.9-3.5] mm Hg; P < 0.001) in both DMR and FMR cohorts. Rates of mechanical complications, such as single leaflet device attachment and leaflet tear, were rare across both device generations but were further reduced in the newer-generation device. The newer-generation device was associated with reduced heart failure (HF) rehospitalization in DMR (adjusted HR: 0.51; 95% CI: 0.33-0.77; P = 0.001) and FMR (adjusted HR: 0.76; 95% CI: 0.61-0.93; P = 0.009), with a greater risk reduction in DMR (Pinteraction < 0.001). A causal mediation analysis revealed that postprocedural TMPG modestly mediated the association between device generation and HF rehospitalization risk (proportion mediated = 1.8% [Q1-Q3: 0.3%-4.0%]; P = 0.016).ConclusionsThe newer-generation TEER system offers a safer and more efficient procedure, with shorter procedural time, fewer mechanical complications, fewer clips, and a lower postprocedural TMPG, contributing to reduced HF rehospitalization risk, particularly in DMR.

Background:Arthroscopic Bankart repair and the remplissage procedure are minimally invasive treatments for anterior shoulder instability. Cadaveric studies have demonstrated the biomechanical effectiveness of these treatments, and clinical studies have reported favorable outcomes; however, quantitative clinical data are required to confirm their in vivo biomechanical efficacy.Hypothesis:Bankart repair and remplissage, based on previous preclinical studies, could significantly reduce anterior humeral head translation (AHHT) in clinical patients.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 29 patients (23 male, 6 female; mean age, 21.7 ± 7.1 years), diagnosed with anterior shoulder instability, were studied between March 2020 and September 2023. Of these patients, 11 underwent only arthroscopic Bankart repair, whereas the remaining 18 underwent remplissage combined with arthroscopic Bankart repair. All procedures were performed under general anesthesia in the beach-chair position. Ultrasonographic evaluations were conducted by the same surgeon immediately pre- and postoperatively. In each shoulder abduction position at 0°, 45°, and 90°, the posterior aspect of the glenohumeral joint was visualized using ultrasonography before and after applying a 40-N anterior force to the upper arm using a handheld dynamometer. AHHT was quantified by measuring the change in distance from the posterior edge of the glenoid to the humeral head due to the traction force at each shoulder angle.Results:Postoperative assessments revealed a significant reduction in AHHT at 90° (from 8.8 ± 5.3 mm to 6.1 ± 2.8 mm; P = .02) of abduction. Subgroup analysis showed that this reduction was significant only when Bankart repair was combined with remplissage (from 10.1 ± 6.0 mm to 5.9 ± 2.9 mm; P = .01). Posterior shifts of the humeral head without traction were observed at 0° (2.7 ± 3.2 mm; P < .001), 45° (2.4 ± 2.7 mm; P < .001), and 90° (3.6 ± 2.5 mm; P < .001) of abduction. Subgroup analysis showed these shifts were significant for all abduction angles except 0° in the group that underwent Bankart repair with remplissage (for Bankart repair alone: [0°] 4.4 ± 3.3 mm, P = .005; [45°] 3.0 ± 3.2 mm, P = .04; and [90°] 4.6 ± 2.1 mm; P < .001; for Bankart repair with remplissage: [0°] 1.6 ± 2.6 mm, P = .06; [45°] 2.1 ± 2.3 mm, P = .006; and [90°] 3.0 ± 2.5 mm, P < .001).Conclusion:Arthroscopic Bankart repair combined with remplissage significantly reduced AHHT at 90° of abduction, whereas Bankart repair alone showed no significant decrease in AHHT at any abduction angle. However, both Bankart repair alone and Bankart repair with remplissage caused a posterior shift of the humeral head without load at 0°, 45°, and 90° of abduction. Measuring AHHT could be critical for assessing postoperative anterior shoulder instability, as it provides the surgeon with objective data to evaluate the procedure's success and guide postoperative management. Future research could investigate clinical differences based on the measured AHHT, potentially providing valuable insights for improving patient outcomes.

Endoscopic cardiac surgery offers favorable early outcomes because of its minimally invasive nature. However, its application in combined aortic and mitral valve procedures remains limited owing to differences in optimal visualization angles and the technical complexity of the procedure. A septuagenarian woman (body surface area 1.2 m2) with severe mitral stenosis, atrial fibrillation, and aortic valve papillary fibroelastoma, who was wheelchair-bound, underwent endoscopic double-valve surgery. Preoperative computed tomography revealed that a single camera port did not provide optimal visualization. Therefore, we employed a dual-camera port setup to facilitate safe mitral valve replacement and aortic tumor resection. The patient recovered uneventfully and was discharged on postoperative day seven. The dual-camera port approach improves visualization and maneuverability in totally endoscopic double-valve surgery, offering a minimally invasive and effective alternative for complex cases, particularly in high-risk patients.

Transcatheter edge-to-edge repair (TEER) is used to treat patients with mitral regurgitation(MR).The Geriatric Nutritional Risk Index (GNRI) is a well-known nutritional marker that predictsmortality risk. The objectives of this study were to elucidate the clinical association between the degree of GNRI and different etiologies of MR and to clarify the patient samples for whom GNRI is more relevant to clinical outcomes following TEER. Data from 3,554 patients with MR who underwent TEER were analyzed using a Japanese multicenter registry. The patients were classified into 4 groups: GNRI<82, GNRI 82 to 92, GNRI 92 to 98, and GNRI >98. Procedural and clinical outcomes were compared between GNRI groups. Short- and long-term all-cause mortality were explored using Cox regression analysis. Among the 3,554 patients, the median GNRI was 92.3. The mean follow-up period was 586.8±436.5days; 806 patients died during the follow-up period. Thirty-day mortality occurred in 51 patients (1.4%), and the GNRI<82 group had the highest 30-day mortality rate. Kaplan-Meier curves showed significantly better prognoses for the entire cohort, functional MR, and degenerative MR across the 4 groups (P<0.001). GNRI values, even after adjustment for multiple confounders, showed a stepwise increase in risk of death in the GNRI 92 to 98, GNRI 82 to 92, and GNRI<82 groups compared to GNRI >98 as the reference. Regardless of MR etiology, GNRI is a useful predictor of short- and long-term mortality in patients undergoing TEER. Although TEER is effective for MR patients in malnourished states, further studies focused on the value of identifying and addressing malnutrition in this population are needed.

Renal impairment is associated with poor clinical outcomes in patients with cardiovascular diseases. Some studies have revealed the impact of renal impairment on the clinical outcomes of patients who underwent mitral valve transcatheter edge-to-edge repair (M-TEER). However, limited data are available regarding the impact of baseline renal impairment after M-TEER in Asian-Pacific patients with heart failure and severe mitral regurgitation. This study sought to examine the effect of renal impairment on clinical outcomes after M-TEER using a large-scale nationwide registry in Japan. A total of 2,150 patients enrolled in the OCEAN-Mitral (Optimized Catheter Valvular Intervention) registry were divided into 3 groups according to the estimated glomerular filtration rate (eGFR) before M-TEER: normal eGFR (≥60mL/min/1.73m2) (n=291), renal impairment (<60mL/min/1.73m2) (n=1,746), and dialysis (n=113). The impact of renal impairment and dialysis on major adverse cardiovascular events (MACE) (a composite of all-cause death and hospitalization for heart failure) was examined. Kaplan-Meier analysis revealed that the renal impairment and dialysis groups had a significantly higher incidence of MACE (survival rates at 2 years: normal eGFR, 74.2% [95%CI: 66.9%-80.1%] vs renal impairment, 63.9% [95%CI: 61.0%-66.6%] vs dialysis, 50.9% [95%CI: 38.2%-62.2%]; P< 0.001). Multivariate Cox regression analysis identified dialysis as the strongest independent predictor of MACE (HR: 1.95; 95%CI: 1.33-2.85; P< 0.001). Renal impairment was associated with an increased incidence of major adverse events, and dialysis was the strongest independent predictor of poor clinical outcomes after M-TEER in Asian-Pacific patients.