Hiroshi Abe

A 72-year-old man presented with acute left lower limb weakness and pain. Acute arterial occlusion was diagnosed, and thrombectomy pathology revealed fibrin-associated diffuse large B-cell lymphoma (FA-DLBCL). No primary lesion was detected on positron emission tomography-computed tomography. However, during radiotherapy for hypopharyngeal cancer, he developed pneumonia and died. Autopsy revealed FA-DLBCL within a mural thrombus distal to an aortic stent graft. A pathological evaluation should be considered in acute limb ischemia with atypical thrombi. FA-DLBCL should be recognized as a potential cause when embolism from mural thrombus is suspected.

Background: Coronary bifurcation lesions account for 20% of all percutaneous coronary interventions. Acute coronary syndromes involve thrombotic conditions; however, methods for assessing this risk in thrombus‐containing bifurcations are unestablished. Aims: This study aimed to determine whether perfusion balloon dilatation can predict the occurrence of side branch occlusion. Methods: A total of 38 acute coronary syndrome patients with 65 side branches undergoing percutaneous coronary intervention using a perfusion balloon were enrolled. Based on the side branch flow during perfusion balloon dilatation, the branches were divided into PB‐SAFE (perfusion balloon side branch‐assisted flow stability, with side branch flow maintained) and not‐SAFE (with side branch flow loss) groups. Results: The PB‐SAFE group did not have cases of side branch occlusion, whereas side branch occlusion occurred in 13 (31.7%) branches in the not‐SAFE group. Further, this group was identified as a significant predictor of side branch occlusion ( p < 0.01). In a lesion‐level multivariable analysis with per‐patient clustering, not‐SAFE remained an independent predictor of side branch occlusion (adjusted OR 20.8, 95% CI 4.08−106, p < 0.01). Conclusion: The PB‐SAFE, our original predictor of side branch occlusion, can predict patients at risk of side branch occlusion during acute coronary syndrome bifurcation lesions.

This case details a 78‐year‐old male with a history of old myocardial infarction and chronic myeloid leukemia treated with tyrosine kinase inhibitors (TKIs). The patient presented with exertional dyspnea and was hospitalized for congestive heart failure. Following the development of a urinary tract infection, the patient exhibited signs of sepsis‐induced cardiomyopathy (SIC), including myocardial injury and rapid hemodynamic deterioration, leading to death. Autopsy findings indicated SIC, characterized by neutrophil‐dominant inflammatory cell infiltration and endothelial damage, which might have been exacerbated by the patient′s preexisting conditions of old myocardial infarction and TKI therapy. This case underscores the multifactorial nature of SIC, suggesting that preexisting old myocardial infarction and TKI therapies can significantly impact the disease′s pathogenesis and progression. It highlights the need for comprehensive management strategies in patients with complex medical histories and the importance of further research to elucidate the underlying mechanisms of SIC.

Background and aims: Successful left atrial posterior wall isolation (LAPWI) using only the cryoballoon (CB) is technically challenging for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy of the cross‐over technique, wherein an overlapped ablation is performed by placing the CB from both directions in contact with the LAPW.Methods: This was a single‐center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first‐time procedure of pulmonary vein isolation (PVI) + PWI (108 patients) or PVI‐only (86 patients) using the CB. The cross‐over technique was applied in all LAPWI.Results: For ablation of the LA roof and bottom, respectively, a mean of 8.6 ± 1.0 (right to left [R→L] 4.3 ± 1.1 and left to right [L→R] 4.3 ± 1.1) and 9.1 ± 1.2 (R→L 4.6 ± 1.6 and L→R 4.5 ± 1.2) CB applications were delivered. LAPW was successfully isolated solely using the CB in 99.1% of patients. Although the PVI + PWI group had significantly longer procedure time, no severe adverse events were observed in either group. During a median follow‐up of 19 months, freedom from recurrence of all atrial tachyarrhythmias was achieved in 93.5% of the PVI + PWI group and 72.9% of the PVI‐only group (p = .011).Conclusions: LAPWI performed solely with the CB using the cross‐over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone in patients with PerAF.

Background: The cryoballoon (CB) has recently been used for performing pulmonary vein isolation (PVI) with concomitant left atrial posterior wall isolation (LAPWI). However, successful LAPWI using only the CB is technically challenging. This study aimed to evaluate the feasibility, safety, and efficacy of the cross-over technique, wherein an overlapped ablation is performed by placing the CB from both left and right directions in contact with the roof and bottom of the left atrium (LA). Methods: This was a single-center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first-time procedure of PVI + PWI (108 patients) or PVI-only (86 patients) using the CB between April 2021 and December 2023. The cross-over technique was applied in all LAPWI using the CB. Results: For ablation of the LA roof and bottom, respectively, a mean of 8.6 ± 1.0 (L→R 4.3 ± 1.1 and R→L 4.3 ± 1.1) and 9.1 ± 1.2 (L→R 4.5 ± 1.2 and R→L 4.6 ± 1.6) CB applications were delivered. LAPW was successfully isolated solely using CB in 107 patients (99.1%). The PVI + PWI group, compared to the PVI-only group, had significantly longer procedure time (180.0 ± 42.4 vs. 78.0 ± 22.1 min, P < 0.001). No severe adverse events were observed in either group. During a median follow-up of 19 months, 93.5% and 72.9% of the PVI + PWI and PVI-only groups, respectively, were free from all atrial tachyarrhythmia recurrence ( P = 0.011). Cox regression analyses showed LA diameter and PVI + PWI were independent predictors of all atrial tachyarrhythmias recurrence. Conclusions: LAPWI performed solely with the CB using the cross-over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone on midterm follow-up in patients with PerAF. WHAT IS KNOWN?: The cryoballoon (CB) has recently been used for performing pulmonary vein isolation (PVI) with concomitant left atrial posterior wall isolation (LAPWI). LAPWI using the CB was previously demonstrated to be superior to PVI alone for the treatment of persistent atrial fibrillation (PerAF). However, successful LAPWI using only the CB is technically challenging, and there is no established LAPWI technique or protocol using the CB. WHAT THE STUDY ADDS?: LAPWI solely with the CB was successfully performed using the cross-over technique, wherein an overlapped ablation was performed placing the CB from both left to right and right to left directions in contact with the roof and bottom of the LA. This technique achieved a high rate of acute success (99.1%) and freedom from recurrence of atrial tachyarrhythmias (93.5%) on a midterm follow-up without increasing adverse events. The cross-over technique could be considered an effective ablation strategy for LAPWI, especially in difficult cases such as narrow and steeply angled LA roof and bottom.

A 48‐year‐old male with a history of hyperlipidemia presented to the emergency department with chest pain. Electrocardiographic abnormalities indicated an acute coronary syndrome. Urgent coronary angiography revealed nondominant right coronary artery (RCA) occlusion. During primary percutaneous coronary intervention (PCI), a 0.014‐inch floppy guidewire could not be easily advanced into the middle RCA due to poor backup support from the guiding catheter and the patient’s breathing. The pressure was monitored several times after reinserting the guiding catheter. Nevertheless, the guidewire was inadvertently inserted into the false lumen from the ostium, leading to subsequent dissection during contrast injection. Intravascular ultrasound (IVUS) imaging confirmed dissection from the ostium to the middle RCA and passage of the guidewire into the false lumen. An additional guidewire was successfully inserted into the true lumen of the RCA using real‐time IVUS‐guided wiring. We demonstrated successful bailout stenting for catheter‐induced dissection of the nondominant small RCA. Our case highlights the risk of coronary artery dissection associated with guiding catheter use, especially in a nondominant small RCA, and the importance of optimal guiding catheter selection for primary PCI. The real‐time IVUS‐guided wiring technique can be applied to a single 6‐Fr guiding catheter and is useful for quickly inserting a guidewire into the true lumen.

Whether malnutrition during the early phase of recovery from acute myocardial infarction (AMI) could be a predictor of mortality or morbidity has not been ascertained. We examined 289 AMI patients. All-cause mortality and composite endpoints (all-cause mortality, nonfatal stroke, nonfatal acute coronary syndrome, and hospitalization for acute decompensated heart failure) during the follow-up duration (median 39 months) were evaluated. There were 108 (37.8%) malnourished patients with GNRIs of less than 98 on arrival; however, malnourished patients significantly decreased to 91 (31.4%) during the convalescence period (p < 0.01). The incidence rates of mortality and primary composite endpoints were significantly higher in the malnourished group than in the well-nourished group both on arrival and during the convalescence period (All p < 0.05). Nutrition guidance significantly improved GNRI in a group of patients who were undernourished (94.7 vs. 91.0, p < 0.01). Malnourished patients on admission who received nutritional guidance showed similar all-cause mortality with well-nourished patients, whereas malnourished patients without receiving nutritional guidance demonstrated significantly worse compared to the others (p = 0.03). The assessment of GNRI during the convalescence period is a useful risk predictor for patients with AMI. Nutritional guidance may improve the prognoses of patients with poor nutritional status.

Background: Cardiopulmonary bypass (CPB) causes a systemic intlammatory response. TNFα, which is a major inflammatory mediator, has been found in the circulation during and after CPB. Although previous studies have shown that heparin coating of the extracorporeal circuits reduces complement and granulocyte activation, and the inflammatory response, the possible effect of heparin coating on TNFα formation and the inflammatory response has not been fully investigated. Methods: Eighteen patients scheduled for coronary artery bypass grafting were divided randomly into two groups. One group of patients had extracorporeal perfusion using heparin coated circuits (HC group, n = 9). The other group had extra‐corporeal perfusion using an identical circuit that was not coated (UC group, n = 9). Blood samples were drawn before, during, and after CPB for measurement of plasma TNFα, plasma IL‐8, neutrophil count, and neutrophil elastase. Results: Plasma levels of TNFα increased during CPB in the UC group but not in the HC group. Plasma concentrations of IL‐8 increased similarly during and after CPB in both groups. Coating the circuits with heparin did not affect the levels of IL‐8. In both groups, the neutrophil count increased after the release of the aortic cross clamp and remained elevated for three days. In the HC group, however, the increase of neutrophil count was significantly lower compared with the UC group. Plasma concentrations of neutrophil elastase were significantly increased during and after CPB in both groups. However, the levels of elastase were significantly lower at certain time points in the HC group. Conclusion: From these observations, we conclude that heparin coating of the extracorporeal circuits reduces the TNFα formation during CPB, which may reduce neutrophil activation.