Circulation reports最新文献

Background: Because the optimal choice of vasopressor for the initial treatment of cardiogenic shock (CS) remains controversial, we conducted a systematic review and meta-analysis to evaluate whether noradrenaline improves clinical outcomes compared with other vasopressors (adrenaline, dopamine, and vasopressin) in patients with CS.

Methods and results: PubMed, CENTRAL, and Web of Science databases were searched for randomized controlled trials (RCTs) and observational studies comparing noradrenaline with other vasopressors in adults with CS. A meta-analysis was conducted using fixed-effect models where appropriate. Two RCTs were included (n=337). One trial enrolled 57 patients and compared the effects of noradrenaline and adrenaline. Another study included 280 patients with CS as a subgroup and compared noradrenaline with dopamine. Pooled analysis showed that noradrenaline likely reduced the 28-day mortality rate compared with other vasopressors (very-low certainty). This corresponded to approximately 110 fewer deaths per 1000 patients (95% confidence interval: 217 fewer to 5 fewer). Secondary outcomes from the Levy study indicated fewer adverse events in the noradrenaline group.

Conclusions: Noradrenaline likely reduces the 28-day mortality rate compared with other vasopressors (very-low certainty) in CS. Given the small number of studies and the potential bias, further large-scale trials are warranted.

Background: Cardiac rupture (CR), encompassing both free wall and ventricular septal ruptures, is a serious complication of ST-segment elevation myocardial infarction (STEMI). In this study, we aimed to investigate the incidence, characteristics, and clinical outcomes of CR in patients with STEMI.

Methods and results: The Japan Acute Myocardial Infarction Registry (JAMIR) is a multicenter prospective study. Of the 3,411 patients hospitalized with acute MI between 2015 and 2017, data from 2,626 patients with STEMI (612 women [23.3%]; median age, 68 years) were analyzed. CR occurred in 34 patients (1.3%), comprising free wall rupture in 25 cases (73.5%), ventricular septal rupture in 8 cases (23.5%), and both in 1 case (2.9%). Compared to those without CR, the cumulative incidence of the primary endpoints (cardiovascular death, non-fatal MI, or non-fatal stroke) at 1 year was significantly higher in the CR group (64.7% vs. 7.9%, log-rank P<0.001). Factors independently associated with CR included older age, anterior wall infarction, and prolonged onset-to-admission time. Notably, the incidence of CR increased with longer onset-to-admission times (0-3 h, 0.6%; 3-6 h, 1.7%; 6-12 h, 1.7%; ≥12 h, 3.6%; P for trend <0.001), but was not associated with door-to-device times (≤90 min, 0.7% vs. >90 min, 1.4%; P=0.156).

Conclusions: CR following STEMI is associated with delayed onset-to-admission time and poor clinical outcomes.

Background: Atrial functional mitral regurgitation (FMR) results from left atrial enlargement and dysfunction, typically observed in patients with atrial fibrillation (AF). Predictors of sinus rhythm maintenance after catheter ablation in atrial FMR patients are not well understood.

Methods and results: We retrospectively reviewed 1,410 consecutive patients who underwent initial catheter ablation for AF at Kobe University Hospital between January 2014 and December 2022. Of these patients, 56 (4%; mean [±SD] age 68±8 years; 68% male) had significant (moderate, n=48; severe, n=8) atrial FMR based on pre-ablation transesophageal echocardiography. At follow-up echocardiography, a reduction in the left atrial diameter (LAd) was observed in 30 patients, whereas improvement in mitral regurgitation (MR) was noted in 26. During a mean follow-up period of 835 days, AF recurred in 23 (41%) patients. Kaplan-Meier curves for AF recurrence did not differ based on LAd reductions or MR improvements alone. However, recurrence rates were significantly lower in patients who achieved both LAd reduction and MR improvement than in those who did not achieve both changes (P=0.0259). Multivariate analysis revealed that the combination of LAd reduction and MR improvement was the only significant predictor of a decrease in AF recurrence (hazard ratio 0.275; 95% confidence interval 0.091-0.826; P=0.021).

Conclusions: In AF patients with significant atrial FMR, achieving both LAd reduction and MR improvement after ablation is important to reduce the risk of AF recurrence.

Background: Left ventricular (LV) dysfunction after mitral valve (MV) repair for degenerative mitral regurgitation (DMR) is a poor prognostic factor. Preoperative LV end-systolic diameter (LVESD) and LV ejection fraction (LVEF) are used in guidelines as indices for LV dysfunction, with cut-off values of 60% for LVEF and 40 mm for LVESD. However, these factors have received little validation in Japanese patients.

Methods and results: We evaluated preoperative echocardiographic data in 322 Japanese patients who underwent MV repair for DMR to identify factors associated with postoperative LV dysfunction. Postoperative LV dysfunction was observed in 31 (10%) patients, who had greater LVESD (39±6 mm vs. 33±5 mm; P<0.001) and lower LVEF (62±5% vs. 67±5%; P<0.001) preoperatively, compared with the non-LV dysfunction group. The optimal threshold of preoperative LVESD and LVEF for predicting postoperative LV dysfunction in receiver operating characteristic curve analysis was 36 mm (AUC=0.819; P<0.001) and 61% (AUC=0.706; P<0.001), respectively. Kaplan-Meier analysis showed a significantly lower rate of avoided adverse cardiac events in the LV dysfunction group (P<0.001).

Conclusions: The criteria for LVESD in MV repair in patients with DMR should be lower than the values indicated by the guidelines. Adoption of these revised criteria may improve prognosis after surgery in Japanese patients.

Background: Spontaneous coronary artery dissection (SCAD) causes acute myocardial infarction (AMI). Clinical characteristics of SCAD patients remain insufficiently understood.

Methods and results: We analyzed AMI patients aged ≤60 years using the nationwide Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination database (2012.04.01-2022.03.31). SCAD was defined by International Classification of Diseases, 10th revision code I24.8 and the presence of keyword 'coronary artery dissection'. The primary outcome was in-hospital all-cause mortality. Among 96,304 eligible patients, 330 (0.34%) had SCAD. SCAD patients were younger (P<0.001), more often female (P<0.001), and had fewer atherogenic risk factors. They less frequently received aspirin (P<0.001), angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (P<0.001), statins (P<0.001), and percutaneous coronary intervention (PCI; P<0.001). After propensity score matching, in-hospital all-cause mortality did not differ between SCAD and non-SCAD patients (1.0% vs. 2.9%; P=0.142). The subgroup analysis revealed that the use of aspirin was associated with a lower adjusted in-hospital all-cause mortality (P=0.002), whereas primary PCI (P=0.223), β-blocker (P=0.646), and statin (P=0.608) were not. Of note, older SCAD patients were more likely to exhibit inferior MI (P=0.036 for trend) with shorter duration of hospitalization (P=0.025 for trend).

Conclusions: Short-term outcomes in SCAD patients are comparable with those of atherosclerotic AMI. While aspirin lowered in-hospital mortality, PCI, β-blocker, and statin did not. Our findings suggest the need for physicians to select appropriate therapeutic management in SCAD patients to achieve better outcomes.

Background: Although mitral valve repair typically leads to left atrial reverse remodeling, persistent left atrial enlargement is associated with poor prognosis. Factors contributing to postoperative left atrial enlargement remain poorly understood. Left atrial strain analysis may offer supplementary evaluation of left atrial function, complementing conventional volume-based assessments.

Methods and results: Echocardiographic data of 76 patients who underwent mitral valve repair for primary mitral regurgitation due to leaflet prolapse were retrospectively analyzed. Left atrial volume index and strain parameters were evaluated preoperatively and 1 year postoperatively. Predictors of postoperative left atrial enlargement (left atrial volume index ≥34 mL/m²) were assessed by logistic regression and receiver operating characteristic analyses. Postoperatively, left atrial volume index decreased significantly (from 64.4±23.1 to 36.6±10.5 mL/m²; P<0.01) and there was a significant decline in left atrial strain parameters. Preoperative left atrial early longitudinal strain rate was an independent predictor of postoperative left atrial enlargement (odds ratio 0.076; 95% confidence interval 0.07-0.80; P=0.032), with a receiver operating characteristic curve-derived cut-off of 0.815%/s (area under the curve 70.2%, sensitivity 81.1%, specificity 59.0%).

Conclusions: Left atrial early longitudinal strain rate is an independent predictor of postoperative left atrial enlargement following mitral valve repair, providing valuable prognostic information.

Background: Acute kidney injury (AKI) is a common and serious post-transcatheter aortic valve replacement (TAVR) complication that affects patient outcomes. Low-flow, low-gradient (LFLG) aortic stenosis (AS) and chronic kidney disease (CKD) represent a high-risk subset of patients undergoing TAVR. The objective of this study was to evaluate the prognostic impact of LFLG-AS and AKI in CKD patients undergoing TAVR.

Methods and results: A retrospective analysis was conducted on 324 patients with CKD stage G3a-5 who underwent TAVR for severe AS between August 2015 and December 2022. Patients were stratified into 4 groups according to the presence of LFLG- AS and AKI. The primary endpoint was defined as all-cause mortality or heart failure during the 2-year follow-up period. During a median period of 13 months, 46 (14%) patients reached the primary endpoint. The difference between the baseline values for renal function of the patients with AKI or without AKI was not significant. The patients without either condition who had the most favorable outcomes were those without LFLG-AS or AKI. Patients with LFLG-AS only or AKI only had intermediate outcomes. The patients with LFLG-AS and AKI showed significantly higher mortality and adverse outcomes than the other groups (log-rank P<0.001).

Conclusions: This study highlighted the severe prognostic implications of AKI for patients with LFLG-AS who undergo TAVR.

Background: Although implantable cardioverter-defibrillators (ICD) offer prognostic benefit for patients with reduced left ventricular ejection fraction (LVEF), they remain underused in Japan.

Methods and results: We analyzed 25 patients who underwent primary prevention ICD implantation. During a median follow-up of 52.6 months, no appropriate shocks occurred, but non-sustained ventricular tachycardia (NSVT) was frequently observed. Two patients underwent antitachycardia pacing. LVEF improved to >35% in nearly half of the patients.

Conclusions: Cardiac resynchronization therapy and pharmacotherapy possibly improved cardiac function. Unnecessary shock delivery programming may have also contributed to the favorable outcomes.

Background: The incidence of atrial fibrillation (AF) is high in lung cancer patients, but the clinical and prognostic significance of AF during the non-perioperative period is unknown.

Methods and results: We performed a retrospective single-center cohort study of consecutive patients diagnosed with primary lung cancer. Of the 383 patients included in this study, 27 (7.04%) developed AF during the non-perioperative period (median follow-up 1.68 years). At the baseline, the AF group had a significantly higher prevalence of age ≥70 years or older, diabetes, heart diseases, chronic kidney disease, and high C-reactive protein (CRP) (>0.6 mg/dL). Multivariate analysis using propensity scores showed that high CRP was an independent risk factor for developing AF (odds ratio 3.08; 95% confidence interval 1.17-8.06; P=0.022). Although most (81.5%) of the AF group had no or mild symptoms, the overall survival rate was significantly lower in the AF than non-AF group. Body mass index ≤25.4 kg/m² was associated with lower survival rate in the AF group, but not in the non-AF group.

Conclusions: In lung cancer patients, the incidence of AF was high during the non-perioperative period, and high CRP was an independent risk factor for developing non-perioperative AF. Although the symptoms were milder, non-perioperative AF was associated with a higher risk of all-cause mortality, and BMI had significant predictive value for mortality.

Extracorporeal membrane oxygenation (ECMO) delivers powerful mechanical circulatory support while simultaneously offering respiratory support; however, it can increase afterload and is associated with potential device-related vascular complications. To date, several randomized controlled trials have failed to demonstrate a prognostic benefit of routine use of ECMO in patients with cardiogenic shock secondary to acute myocardial infarction or in those with out-of-hospital cardiac arrest. Therefore, the routine use of ECMO is not a guideline-recommended therapeutic strategy. However, in real-world clinical practice, a considerable proportion of patients with cardiogenic shock and cardiac arrest have no other therapeutic options besides ECMO to save their life. Additionally, a combination of ECMO with other mechanical circulatory support devices, such as an intra-aortic balloon pump and percutaneous ventricular assist device, may help reduce the limitations of ECMO and improve patient outcomes. The results of ongoing randomized trials will shape our understanding of the role of ECMO itself and the combination strategies in patients with cardiogenic shock and out-of-hospital cardiac arrest.