Kiyoshi Hibi

Background: Fluoroscopic assessment enables immediate evaluation of transcatheter heart valve expansion during transcatheter aortic valve replacement (TAVR). Whether fluoroscopic asymmetric expansion of balloon‐expandable valves is associated with post‐TAVR heart failure (HF) remains uncertain. Methods: Among 607 consecutive patients undergoing balloon‐expandable valve‐TAVR in a prospective registry, 589 were analyzed. Valve asymmetry was quantified using a fluoroscopic asymmetry index (%), defined as [(longest/shortest balloon‐expandable valve height)−1]×100. The primary end point was 2‐year HF hospitalization. Results: During follow‐up, 99 patients (17%) experienced HF hospitalization. As a continuous variable, asymmetry index (%) was not independently associated with 2‐year HF (adjusted hazard ratio [HR] per 1% increase, 1.02 [95% CI, 0.98–1.06]). Restricted cubic spline analysis demonstrated no significant linear or nonlinear association (overall P =0.71; P for nonlinearity=0.89), although the risk curve suggested increased HF risk beyond moderate valve asymmetry. Exploratory threshold analysis identified an asymmetry index cutoff of 7.48%. Patients above this threshold had a higher incidence of HF hospitalization than those below it (23.6% versus 15.8%; log‐rank P =0.043), despite comparable rates of impaired valve performance at discharge. Valve asymmetry >7.48% remained independently associated with late HF occurring beyond 30 days after TAVR (adjusted HR, 1.69 [95% CI, 1.10–2.60]). Conclusions: Fluoroscopic assessment of balloon‐expandable valve expansion identified patients with marked valve asymmetry at increased risk of late HF after TAVR, despite preserved early valve performance. These findings support the potential value of intraprocedural valve geometry assessment for long‐term risk stratification and warrant further investigation.

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Background: The Arterial Velocity Pulse Index (AVI) and Arterial Pressure–Volume Index (API) are novel non-invasive indices of arterial stiffness derived from cuff-oscillometric measurements. Previous studies have shown that elevated AVI and API are associated with the severity of coronary artery disease and the ability to predict future cardiovascular events. However, the hemodynamic and echocardiographic characteristics of patients with concomitantly high AVI and API remain unclear. Methods: We retrospectively analyzed 112 consecutive cardiovascular outpatients (mean age 69.1 ± 12.2 years, 64.3% male) seen between January and April 2019 at Yokohama City University Hospital. The AVI and API were measured using a multifunctional sphygmomanometer (PASESA AVE1500, Shisei Datum, Japan) and averaged over a maximum of three measurements. Patients were classified into four groups according to previously established cutoff values (AVI ≥ 27, API ≥ 32). Central arterial pulse wave parameters were assessed using SphygmoCor XCEL (AtCor Medical, Sydney, Australia), and echocardiographic parameters were obtained according to standard protocols. Intergroup differences were analyzed using the Kruskal–Wallis test with Steel–Dwass post hoc comparisons. Results: Compared with the low-risk group (low AVI/low API), the high-risk group (high AVI/high API) had significantly higher brachial systolic BP (139.2 [132.8–149] vs. 128 [120–136.7] mmHg, p = 0.0011), central systolic BP (127.5 [122.3–139] vs. 117.7 [110.3–123.7] mmHg, p = 0.0018), and central pulse pressure (56.2 [51.4–60.3] vs. 37.7 [32–43] mmHg, p < 0.001). The forward and reflected wave amplitudes were significantly greater, with prolonged ejection duration and aortic T2 time. The Buckberg subendocardial viability ratio was significantly lower in the high-risk group (129.5 [119.7–145.2] vs. 148.3 [130–168.3], p = 0.040). Echocardiography revealed reduced e′ velocity (5 [4.1–5.8] vs. 6.7 [5.2–8] cm/s, p = 0.035) and increased E/e′ (13.2 [11.1–15.1] vs. 9.7 [7.9–11.3], p = 0.026) in the high-risk group, suggesting the presence of impaired diastolic function without reduced LVEF. Conclusions: Patients with high AVI and API exhibited greater central and peripheral arterial stiffness, higher systolic and pulse pressures, and impaired diastolic function compared with those with low values. These findings support the use of a cardiovascular pathophysiological model in which elevated AVI/API identify individuals at increased risk of progression to heart failure and ischemic heart disease.

Structured Background: Cardiogenic shock (CS) remains a leading cause of in-hospital mortality in acute myocardial infarction (AMI). Although advanced age is associated with worse outcomes, the prognostic relevance of chronological age may vary by clinical presentation, particularly in the presence of out-of-hospital cardiac arrest (OHCA). We investigated the prognostic impact of octogenarian status in patients with AMI complicated by cardiogenic shock (AMI–CS). Methods: We analyzed patients with AMI–CS enrolled in the multicenter Kanagawa-ACuTe cardIoVascular rEgistry (K-ACTIVE) who underwent percutaneous coronary intervention (PCI). Octogenarian status (≥80 years) was the primary exposure. Multivariable logistic regression was used to evaluate associations with in-hospital mortality, and effect modification by OHCA was assessed. Model performance was evaluated using discrimination and decision curve analysis. Results: Among 658 patients with AMI–CS, 177 (26.9%) were octogenarians, and 279 (42.4%) died during hospitalization. In the primary multivariable analysis, octogenarian status was independently associated with higher in-hospital mortality (adjusted odds ratio [aOR], 2.09; 95% CI, 1.33–3.27). This association was evident among patients without OHCA, whereas no clear age-related gradient was observed among those presenting with OHCA. In multivariable models, heart rate and serum albumin provided incremental prognostic information beyond chronological age. Conclusion: In patients with AMI–CS, the prognostic impact of advanced age varies according to clinical presentation. While advanced age confers excess risk among patients without OHCA, its prognostic value appears limited among those presenting after cardiac arrest. These findings support risk stratification strategies that integrate physiological markers beyond chronological age alone to guide individualized clinical decision-making. Key Points: The prognostic impact of age in acute myocardial infarction complicated by cardiogenic shock is highly context dependent. Octogenarian status was associated with increased mortality among patients without out-of-hospital cardiac arrest (OHCA), whereas no meaningful association was observed among those presenting with OHCA. Unmeasurable vital signs, particularly heart rate, represent clinically meaningful physiological derangement rather than missing data. These parameters added prognostic information beyond that provided by conventional clinical variables. Serum albumin and heart rate, which are routinely available at presentation, appeared to capture aspects of physiological vulnerability not fully explained by chronological age alone. Clinical Perspective: What Is New?: The prognostic relevance of age in AMI complicated by cardiogenic shock (AMI–CS) was not uniform and differed according to clinical presentation. Octogenarians exhibit substantially higher mortality among patients without OHCA, whereas age did not meaningfully influence mortality after OHCA. Unmeasurable vital signs represent clinically informative, missing-not-at-random indicators of disease severity. Explicit modeling of unmeasurable systolic blood pressure and heart rate strengthened prognostic assessment. Serum albumin and heart rate provide prognostic information beyond chronological age in AMI–CS. What Are the Clinical Implications?: Chronological age alone should not determine the aggressiveness of care in patients with AMI–CS. Among patients without OHCA, advanced age may identify a biologically vulnerable subgroup that could benefit from timely revascularization and selectively applied mechanical circulatory support. In patients with OHCA, prognosis appears to be driven predominantly by post–cardiac arrest injury rather than age. Incorporating serum albumin and heart rate into risk assessment may support more equitable, phenotype-based clinical decision-making.

Background: Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality, despite advances in treatment. Early detection of vascular aging is critical, as preclinical atherosclerosis often remains undiagnosed. AI-determined vascular age, originally developed using carotid-femoral pulse wave velocity (cf-PWV), may help to identify individuals at elevated risk. This study aimed to evaluate the clinical utility of an alternative AI-determined vascular age model based on the arterial velocity pulse index (AVI) and arterial pressure volume index (API) in a Japanese hospital-based cohort. Methods: This retrospective, exploratory study analyzed electronic health records of 408 patients from Yokohama City University Hospital. This study was approved by the Clinical Research Ethics Committee (approval numbers: B180300040, F240500007), and patient consent was obtained through an opt-out process. AI-determined vascular age was estimated using a Generalized Additive Model (GAM) with backward stepwise regression, substituting cf-PWV with AVI and API. Correlations with chronological age were assessed, and comparisons of cardiovascular and renal function markers were performed across age-stratified groups. Results: AI-determined vascular age showed a strong correlation with chronological age (p < 0.05). Significant differences were observed in cardiac diastolic function parameters, B-type natriuretic peptide (BNP), and estimated glomerular filtration rate (eGFR) between the highest and lowest quintiles of AI-determined vascular age. Conclusions: AI-determined vascular age using AVI and API appears to be a feasible surrogate for cf-PWV in clinical settings. This index may aid in stratifying vascular aging and identifying individuals who could benefit from early cardiovascular risk management.

It remains unknown whether intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) can improve the clinical outcomes of complex PCI to a level equivalent to that of non-complex PCI. In the OPTIVUS-Complex PCI (Optimal Intravascular Ultrasound-Guided Complex PCI) Study multivessel cohort, a total of 1011 patients who underwent multivessel PCI involving a target lesion in the left anterior descending coronary artery (LAD) were divided into 2 groups: complex PCI (N = 760) and non-complex PCI groups (N = 251). Complex PCI was defined as a procedure with the following characteristics: 3 vessels treated, 3 stents implanted, 3 lesions treated, bifurcation with 2 stents implanted, total stent length > 60 mm, or target of chronic total occlusion. The primary endpoint was major adverse cardiac and cerebrovascular event (MACCE) defined by a composite of death, myocardial infarction, stroke, or any coronary revascularization. The cumulative 1-year incidences of the primary endpoint and any coronary revascularization were not significantly different between the complex and non-complex PCI groups (10.9% vs. 8.3%, P = 0.24, and 7.7% vs. 4.8%, P = 0.12, respectively). In the multivariable Cox proportional hazards models, there was no significant excess risk of the complex PCI group relative to the non-complex PCI group for the primary endpoint (HR, 1.35; 95%CI, 0.83–2.18; P = 0.22), or for any coronary revascularization (HR, 1.64; 95%CI, 0.87–3.06; P = 0.11). After optimal IVUS-guided multivessel PCI with a target lesion in the LAD, 1-year risk of MACCE or coronary revascularization in patients with complex PCI was numerically higher than that in patients with non-complex PCI. Graphical Abstract

Background: In 2023, Japan had the highest proportion of the elderly in the world, with one in 10 individuals aged ≥80 years. Consequently, the number of patients with cardiovascular diseases is increasing. Older patients often have comorbidities such as frailty, sarcopenia, and cognitive decline that leads to a decreased quality of life (QOL). We analyzed the effects of outpatient cardiac rehabilitation (OCR) in elderly patients with cardiovascular disease. Methods: The comprehensive OCR had been provided by a multidisciplinary team. We analyzed data from 49 patients with cardiovascular diseases, aged ≥80 years, who received cardiopulmonary exercise (CPX) tests based OCR. Frailty, physical function, QOL, exercise tolerance, and vascular endothelial function were assessed before and after OCR. Results: All 49 patients had completed the OCR program. The mean patients' age was 84.1 ± 3.6 years and 32.7% were male. The proportion of frailty and pre-frailty participants significantly decreased from 92% to 67% following OCR. The QOL (KCCQ: 76.8 ± 18.4 vs. 81.4 ± 20.4; P = 0.0196), exercise tolerance (peak VO₂: 14.1 ± 4.0 vs. 15.4 ± 3.9 mL/min/kg; P = 0.0017), and vascular endothelial function (Ln-RHI: 0.48 ± 0.39 vs. 0.57 ± 0.3; P = 0.027) significantly improved after OCR. Conclusions: The comprehensive OCR with CPX-based exercise therapy and the multidisciplinary approach significantly improved frailty, the QOL, physical function, exercise tolerance, and vascular endothelial function in patients with cardiovascular diseases aged ≥80 years.

Background: The effect of worsening renal function and baseline chronic kidney disease (CKD) on outcomes in patients with chronic coronary syndrome in the setting of optimal medical therapy remains unknown. Methods and Results: The REAL‐CAD (Randomized Evaluation of Aggressive or Moderate Lipid Lowering Therapy With Pitavastatin in Coronary Artery Disease) study is a prospective, multicenter, randomized trial of high‐dose (pitavastatin 4 mg/day) or low‐dose (pitavastatin 1 mg/day) statin therapy in 12 118 patients with chronic coronary syndrome. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, stroke, or unstable angina requiring hospitalization (major adverse cardiac and cerebral events [MACCE]). CKD was defined as an estimated glomerular filtration rate [eGFR] 2 . WRF was defined as a decrease in eGFR ≥20% in the initial year; borderline renal function was an annual decrease of 0%P P =0.039]). In patients without CKD, borderline renal function was a significant predictor for MACCE at 4 years compared with stable renal function (HR: 1.40 [95% CI, 1.03–1.91; P =0.032]). Conclusions: Baseline CKD was an independent predictor for MACCE in patients with CCS. WRF was a significant predictor for MACCE in patients with CKD. Because borderline renal function was an independent predictor for MACCE even in patients without CKD, mild‐to‐moderate annual declines of eGFR should be carefully monitored (NCT01042730). Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT01042730.

Background: A delayed and recurrent complete atrioventricular block (CAVB) is a life‐threatening complication of transcatheter aortic valve replacement (TAVR). Post‐TAVR evaluation may be important in predicting delayed and recurrent CAVB requiring permanent pacemaker implantation (PPI). The impact of new‐onset right bundle‐branch block (RBBB) after TAVR on PPI remains unknown. Methods and Results: In total, 407 patients with aortic stenosis who underwent TAVR were included in this analysis. Intraprocedural CAVB was defined as CAVB that occurred during TAVR. A 12‐lead ECG was evaluated at baseline, immediately after TAVR, on postoperative days 1 and 5, and according to the need to identify new‐onset bundle‐branch block (BBB) and CAVB after TAVR. Forty patients (9.8%) required PPI, 17 patients (4.2%) had persistent intraprocedural CAVB, and 23 (5.7%) had delayed or recurrent CAVB after TAVR. The rates of no new‐onset BBB, new‐onset left BBB, and new‐onset RBBB were 65.1%, 26.8%, and 4.7%, respectively. Compared with patients without new‐onset BBB and those with new‐onset left BBB, the rate of PPI was higher in patients with new‐onset RBBB (3.4% versus 5.6% versus 44.4%, P <0.0001). On post‐TAVR evaluation in patients without persistent intraprocedural CAVB, the multivariate logistic regression analysis showed that new‐onset RBBB was a statistically significant predictor of PPI compared with no new‐onset BBB (odds ratio [OR], 18.0 [95% CI, 5.94–54.4]) in addition to the use of a self‐expanding valve (OR, 2.97 [95% CI, 1.09–8.10]). Conclusions: Patients with new‐onset RBBB after TAVR are at high risk for PPI.