Takeshi Suetomi

Extract About 20% of patients with haemodynamically severe PAH achieved near-normal haemodynamics and safely de-escalated parenteral prostacyclin. Early intensive treatment may be key to maintaining near-normal haemodynamics after prostacyclin discontinuation.

Objective: Severe aortic stenosis (AS) is a life-threatening valvular disease with an in-hospital mortality rate exceeding 50% when complicated by cardiogenic shock. In this critical setting, emergency balloon aortic valvuloplasty (BAV) is sometimes performed as an initial therapy. However, reports on emergency BAV followed by Impella (Abiomed, Danvers, MA, USA) support, referred to as the BAV-PELLA strategy, remain limited.Case Presentation: We report 4 patients who were treated using this strategy. This staged management markedly reduced the surgical risk scores in all 4 cases. Three of the 4 patients underwent elective definitive valve replacement after a preoperative window that provided sufficient time for hemodynamic stabilization and a comprehensive assessment of surgical candidacy. One patient required urgent surgical aortic valve replacement (SAVR) with coronary artery bypass grafting under continued combined venoarterial extracorporeal membrane oxygenation and Impella (ECPELLA) support. Among the remaining 3 patients, 1 underwent isolated SAVR, 1 underwent SAVR with mitral valve repair, and 1 underwent transcatheter aortic valve replacement (TAVR) after stabilization. Following emergent BAV, Impella placement was successfully performed in all patients, despite the persistence of severe AS. No procedure-related complications associated with BAV or Impella implantation were observed.Conclusion: The BAV-PELLA strategy not only supports circulatory recovery in the acute phase but also provides a valuable preoperative window, enabling individualized definitive therapy based on the patient’s condition.

Background: Sustainability of the 24/7 acute coronary syndrome response system is at risk due to the Work Style Reform for physicians.Methods and Results: A survey of 93 facilities in Chugoku-Shikoku region found that 30% of facilities expected acute coronary syndrome services to be restricted due to the Work Style Reform. Approximately 35% had implemented task shifting, which reduced physicians’ workload by 30% and improved team care.Conclusions: Task shifting improved the working environment. However, various barriers to implementation were also identified. Further investigation is needed to achieve a balance between the Work Style Reform and sustainability of the acute coronary syndrome response system.

Klippel–Trenaunay–Weber syndrome (KTWS) is a rare congenital disorder characterized by cutaneous capillary malformations, bone hypertrophy, and multiple venous or lymphatic malformations. KTWS is associated with chronic thromboembolic pulmonary hypertension (CTEPH), presumably due to thromboembolism from multiple vascular malformations. Here, we report the first case series of patients with KTWS‐CTEPH who underwent balloon pulmonary angioplasty (BPA). Both patients are alive 20 years and 1 year after the initial diagnosis of CTEPH, respectively, and are stable with improved hemodynamics. BPA may be an effective treatment option for patients with KTWS‐CTEPH.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) requires life-long anticoagulant therapy, whereas limited data exist on the safety and efficacy of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) along with balloon pulmonary angioplasty (BPA). Objectives: To evaluate outcomes and complications in CTEPH following BPA for individuals receiving DOACs or VKAs. Methods: Consecutive CTEPH patients underwent BPA from September 2014 to August 2021 were included in a retrospective analysis. Complications during BPA, post-BPA hemodynamics and bleeding events were obtained from patient's medical records. Our routine follow-up “selective” pulmonary angiography, to evaluate all segmental pulmonary arteries one by one at six months and every year after final BPA session, was performed to elucidate the incidence of in-situ fresh floating thrombus. Results: Of total 250 individuals, 104 were treated with DOACs and 146 with VKAs following BPA. Mean observation period was 905 (SD ± 660) days. Total 1278 BPA sessions were performed among the period in which 409 sessions were treated with DOACs and 869 sessions with VKAs. Significant improvements in hemodynamics and functional status were observed in both groups following BPA. There was no significant difference of hemoptysis during BPA between DOACs and VKAs (7.1% vs 10.1%, P=0.131). Major bleeding events during observation period were equivalent in those treated with DOACs and VKAs. No significant re-elevation of pulmonary artery pressure was observed in both groups after BPA. Follow-up selective pulmonary angiography identified in-situ fresh floating thrombus in pulmonary artery in 22 cases of total 769 follow-up sessions. The occurrence of fresh thrombus was significantly higher in those receiving DOACs than VKAs in therapeutic range of PT-INR >1.8 (3.9% vs 1.2%, P=0.023) whereas no significant difference between DOACs and overall VKAs (3.9% vs 2.4%, P=0.177) Conclusions: Post-BPA hemodynamic outcomes and bleeding events appear unaffected by choice of anticoagulant. However, the incidence of in-situ pulmonary thrombosis detected by selective pulmonary angiography was significantly higher in those receiving DOACs than VKAs in therapeutic range, suggesting inadequate anticoagulation under current dose of DOACs. Our study provides a rationale for further examination to evaluate the efficacy of DOACs in CTEPH. Funding Acknowledgement: Type of funding sources: None.