井澤 英夫

Background 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is a pivotal tool for diagnosing cardiac sarcoidosis, but its prognostic value during the phase of stable medical and device therapy after initiation of immunosuppressive therapy remains unclear. We aimed to evaluate the prognostic significance of cardiac FDG uptake in patients with cardiac sarcoidosis after treatment initiation. Methods We retrospectively analyzed 79 patients who underwent FDG-PET/CT ≥ 12 months after initiating immunosuppressive therapy (June 2013–October 2023). Patients were categorized into the cardiac accumulation (+) and (-), and Cardiac metabolic activity (CMA) was also quantitatively measured. Major adverse cardiac events—including cardiac death, ventricular arrhythmias, ICD therapy, and heart failure hospitalization—were evaluated. Results Patients in the cardiac accumulation (+) had a higher 2-year incidence of major adverse cardiac events than those in the cardiac accumulation (-), as determined by Kaplan–Meier analysis (log-rank P = 0.030), but FDG uptake was not identified as a predictor in Cox regression analysis. In long-term outcomes, the incidence of cardiac events tended to be higher in the cardiac accumulation (+) group, although this difference did not reach statistical significance (log-rank P = 0.078). Among patients with preserved left ventricular ejection fraction (LVEF ≥50%, independently associated with fewer events), annual cardiac event rates were similarly low regardless of uptake status (1.3% vs. 0.8%; log-rank P = 0.91). In 41 patients who underwent repeat PET imaging, CMA significantly decreased (median 4.83 to 0.82, P = 0.038). Among 23 patients without intensified immunosuppression despite uptake, it resolved spontaneously in 8 patients. Conclusions Follow-up cardiac FDG uptake may be associated with an increased risk of short-term events but has limited value for predicting long-term prognosis. LVEF and the temporal dynamics of FDG uptake should be considered when managing cardiac sarcoidosis.

AIMS: The global distribution of lipoprotein(a) [Lp(a)] levels varies due to racial and ethnic differences. However, the clinical relevance of Lp(a) levels in Japanese patients has not been fully explored. METHODS: We investigated the association of Lp(a) levels, the Suita score, and the presence of high-risk plaque (HRP) as well as that of ≥ 50% stenosis, quantitative plaque volume, and the value of coronary artery calcium score in coronary computed tomographic angiography (CCTA), among 272 Japanese patients (mean age: 65 years) in whom serum Lp(a) levels were measured due to suspected coronary artery disease. HRP was defined as positive remodeling and/or low attenuation. Plaque volume was quantified as the percent plaque volume. RESULTS: HRP was identified in 33 (12.1%) patients. The prevalence of HRP, ≥ 50% stenosis, and percent plaque volume progressively increased with higher Lp (a) levels and Suita scores. In multivariate analyses, Lp(a) and the Suita score independently predicted HRP when assessed as continuous (p = 0.02, p＜0.001, respectively) or categorical variables (p = 0.005, p = 0.007, respectively). Patients in the highest tertile of Lp(a) and classified as high- or intermediate-risk by the Suita score had the highest HRP risk, whereas those in the lower 2 tertiles and low-risk group had the lowest. Incorporating Lp(a) into the Suita score improved the prediction of HRP beyond the Suita score alone (p = 0.005). CONCLUSIONS: The combinatorial value of assessing Lp(a) levels and Suita score may provide useful insight regarding Japanese patients undergoing CCTA for the prediction of HRP.

AIMS: In percutaneous coronary intervention (PCI), a suboptimal choice of guiding catheter may compromise coaxial alignment and backup support, prolonging procedures and increasing radiation and contrast exposure. We assessed whether a computed tomography (CT)-driven, artificial intelligence (AI)-guided preprocedural simulation could improve procedural efficiency and safety. METHODS AND RESULTS: In a single-centre prospective registry with historical controls, 55 consecutive elective procedures performed with CT-based AI-assisted guiding-catheter selection were compared with 55 procedures performed without assistance. The primary endpoint was total procedure time from arterial access to completion. Secondary endpoints included time to coronary engagement, radiation dose, contrast volume, and guiding-catheter-related events. Computed tomography--based AI assistance was associated with shorter procedures (mean 68.5 vs. 91.8 min), shorter engagement time, lower radiation dose, and lower contrast use. Guiding-catheter exchanges were fewer, and catheter-related events were lower (3.6 vs. 16.4%; risk ratio 0.22; 95% confidence interval 0.05-0.98). Procedural success was 100% in both groups with no in-hospital major adverse cardiac or cerebrovascular events. CONCLUSION: A CT-driven, CT-based AI-guided simulation for guiding-catheter selection was associated with greater procedural efficiency and a favourable profile in elective PCI. This approach, which standardizes catheter choice and is associated with fewer empirical catheter exchanges, warrants confirmation in multicentre randomized studies and may help optimize resource utilization in routine PCI.

Reports regarding coronavirus disease 2019 (COVID-19) with Fontan circulation are limited. Most studies indicate a relatively good clinical outcome in which SARS-CoV-2 infection is abated; however, COVID-19 can still cause severe pneumonia, and some studies report circulatory breakdown associated with acute respiratory distress syndrome in patients with Fontan circulation. We present the case of a 32-year-old Japanese woman with right isomerism and a single right ventricle who had undergone a fenestrated extracardiac total cavopulmonary connection (Fontan operation), atrioventricular valve replacement, and pacemaker implantation. Despite receiving three doses of the severe acute respiratory syndrome coronavirus 2 mRNA vaccine, the patient contracted COVID-19 and presented with pneumonia. Although her symptoms were mild, the patient was classified as high-risk based on the European Society of Cardiology risk stratification guidelines for COVID-19 in patients with adult congenital heart disease and was admitted to the hospital. Initially, the patient received only symptomatic treatment. However, 2 days later, the patient's COVID-19 condition worsened to moderate grade level II (SpO2 ≤93%, oxygen demand), with SpO2 dropping from 95% to 88% on room air. Treatment with remdesivir and dexamethasone following Japanese treatment protocols resulted in clinical improvement and discharge without hemodynamic complications. COVID-19 pneumonia risks disrupting Fontan circulation in affected patients. This case illustrates the importance of prompt risk stratification using anatomical and physical evaluation and adherence to treatment guidelines in the management of patients with Fontan circulation and COVID-19.

OBJECTIVES: A new classification of heart failure based on the effects of medication has recently come into use. According to this classification, heart failure is divided into heart failure with normal ejection fraction (HFnEF; defined as an EF ≥55% for men and ≥60% for women) and non-HFnEF. However, the characteristics of patients with HFnEF are still unclear. Accordingly, in this study, we sought to identify the background characteristics, including non-cardiac factors, of patients with HFnEF. METHODS: We retrospectively divided 304 eligible patients who were hospitalized for worsening heart failure at our institution between December 2020 and December 2022 into an HFnEF group (n=37) and a non-HFnEF group (n=267) and compared their demographic and clinical characteristics. RESULTS: There were more elderly patients in the non-HFnEF group, along with fewer patients with coronary artery disease and low serum hemoglobin and NT-proBNP levels and a higher proportion of patients with a low skeletal muscle index (<7.0 kg/m2 for men and <5.7 kg/m2 for women). Multivariate analysis with addition of patient sex identified a low skeletal muscle index (odds ratio 2.96, p<0.01) to be an independent determinant of HFnEF along with older age and low NT-proBNP. CONCLUSIONS: A low skeletal muscle index was significantly more common in patients with HFnEF than in those with non-HFnEF. Intensive nutrition and exercise therapy to increase skeletal muscle mass may improve the prognosis in patients with HFnEF who respond poorly to standard pharmacological treatment.