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Background Balloon pulmonary angioplasty (BPA) improved pulmonary arterial compliance (CPA) and exercise tolerance in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Objectives To investigate whether CPA is a useful index to indicate exercise tolerance improvement by BPA in CTEPH patients. Methods The correlation between changes in CPA and improvements in 6-minute walk distance (6MWD) by BPA was retrospectively analyzed in 70 patients (Analysis 1), and it was sequentially analyzed in 46 symptomatic patients who achieved mean pulmonary arterial pressure (mPAP) Results We enrolled 70 patients (female/male:57/13, mean age:59 years) who underwent a total of 352 BPA sessions which significantly increased CPA (1.5±0.8 vs. 3.0±1.0 mL/mmHg) and decreased pulmonary vascular resistance (PVR) (8.0 ± 3.9 vs. 3.6 ± 1.7 wood units). The correlation coefficient between improvement in 6MWD and changes in PVR and CPA were r=0.21 (p=0.09) and r=0.14 (p=0.26) (Analysis 1). In Analysis 2, those were r=0.32 (p=0.06) and r=0.38 (p=0.02), respectively. Conclusions CPA can be a useful index to indicate the improvement in exercise tolerance by BPA in symptomatic patients with lower mPAP.

Background: The latest guideline from the European Society of Cardiology and European Respiratory Society recommends initial combination therapy with oral pulmonary arterial hypertension (PAH)-specific drugs in PAH patients with World Health Organization functional class (WHO-FC) II or III. However, whether this initial combination therapy improves hemodynamics and clinical failure events regardless of the combination of PAH-specific drugs remains unknown. This study was designed to evaluate whether the initial combination therapy with macitentan plus riociguat or macitentan plus selexipag showed equal efficacy in reducing pulmonary vascular resistance (PVR) 8 months after administration. Methods and Results: This study is a multicenter randomized control trial. PAH subjects with WHO-FC II or III will be randomized (1 : 1) into initial combination therapy with either macitentan plus riociguat or macitentan plus selexipag, and will be observed 8 months after the initiation of treatment. The primary endpoint will be the difference in the change ratio of PVR from baseline to after 8 months of treatment. Conclusions: The SETOUCHI-PH study will clarify whether initial combination therapy with macitentan plus riociguat or macitentan plus selexipag results in equal reductions in PVR 8 months after administration.

AIMS Chronic thromboembolic pulmonary hypertension (CTEPH) is characterised by organised thrombotic obliteration of major vessels and small-vessel arteriopathy in the non-thrombosed vessels. The aim of this study was to investigate the impact of balloon pulmonary angioplasty (BPA) on the non-BPA-side pulmonary vasculature in patients with CTEPH. METHODS AND RESULTS This study explored the outcomes of 20 unilateral BPA sessions in 13 CTEPH patients. We measured the pulmonary vascular resistance (PVR), pulmonary artery (PA) flow in the BPA-side and non-BPA-side lungs, respectively, using phase contrast MRI and cardiac catheterisation. The interval from BPA to the follow-up evaluation was 92.8±52.0 days. A single session of BPA decreased mean PA pressure from 37.4±6.2 to 30.9±6.5 mmHg (p

Background Right ventricular (RV) pressure overload is directly related to the increase in mortality in pulmonary hypertension. Pulmonary arterial compliance (CPA; stroke volume/pulmonary pulse pressure) was reported to be an independent determinant of RV systolic afterload in patients with pulmonary arterial hypertension (PAH). Recently, balloon pulmonary angioplasty (BPA) has been reported to reduce mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (RPA) in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, the effects of BPA on CPA remain unclear. Purpose The aim of this study was to investigate the impact of BPA on CPA in patients with inoperable CTEPH. Methods We retrospectively analyzed 78 patients (388 BPA sessions) with inoperable CTEPH who underwent BPA in our hospital from September 2012 to June 2018. Total number of BPA sessions was 5.0±1.8 (range 1–10). The pressure values were obtained from right heart catheterization at baseline (n=78), just after the final BPA (n=78) and follow-up (n=19) periods. The intervals from baseline to the final BPA and the final BPA to follow-up were 593±498 days and 397±276 days, respectively. Results Mean age was 60.5±12.6 years old, and 64 (82%) were female. All patients were symptomatic (WHO functional class II/III/IV 16/55/7). Patients who had pulmonary vasodilators decreased from 70 (90%) at baseline to 23 (28%) at the final BPA and 2 (15%) at follow-up. BPA reduced mPAP and RPA significantly from baseline to the final BPA and follow-up periods. BPA also improved CPA with significant reduction of pulse pressure despite no significant changes in stroke volume between baseline and follow-up (Table). CPA between the final BPA and follow-up was equivalent (p=0.95). Conclusions BPA improved CPA just after the final BPA in inoperable CTEPH patients. In addition, CPA was preserved during the follow-up after the final BPA sessions. These data suggest that BPA consistently unloads RV systolic afterload in those patients.

Key Clinical Message We describe the case that persistent atrial fibrillation refractory to rhythm control by pharmacotherapy and electrical cardioversions caused tachycardia‐induced cardiomyopathy with low ejection fraction and hemodynamic instability. Mechanical hemodynamic support using an intra‐aortic balloon pump is one of the choices of hemodynamic support during catheter ablation by pulmonary vein isolation.

A 73-year-old woman who had undergone percutaneous coronary intervention (PCI) with a drug-eluting stent in the proximal tortuous right coronary artery (RCA) 5 years previously was referred to our hospital because of unstable angina due to in-stent restenosis. During PCI, a drug-eluting stent with its delivery system became entrapped at the proximal edge of the previously placed stent, with its proximal half expanded into the aorta. The entrapped coronary stent was locked in the proximal tortuous RCA. We successfully retrieved the entrapped coronary stent with its delivery system by dilating a low-profile balloon at the entrapped site and dislocating the locking point (102 words).

Background Pulmonary hypertension (PH) is a life-threatening complication in patients with chronic kidney disease on hemodialysis (CKD-HD). Objectives To determine whether subcutaneous infusion of treprostinil was effective and tolerable CKD-PH. Methods and results A 57-year-old man was admitted to our hospital due to presyncope and dyspnea during exercise with a history of CKD-HD. Cardiac catheterization revealed high pulmonary arterial pressure (PAP) of 53/24/32 mmHg and pulmonary vascular resistance (PVR) of 11.2 w.u. Upfront combination therapy with bosentan and sildenafil was started. However, 6-month therapy did not attenuate his symptoms, probably due to the high PAP and PVR (60/19/30 mmHg and 5.9 w.u.). We added subcutaneous treprostinil. Surprisingly, 9-month treprostinil (50 ng/kg/min) normalized hemodynamics (PAP: 25/4/13 mmHg and PVR: 1.9 w.u.). His symptoms during excise disappeared without any adverse effects. Conclusion This is the first report that subcutaneous treprostinil was very effective and tolerable in a PH patient with CKD-HD.

To use cardiac magnetic resonance imaging (MRI) to investigate the effect of balloon pulmonary angioplasty (BPA) on interventricular dyssynchrony and its associations with ventricular interaction, which impairs LV function in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). This prospective observational study was approved by our institutional review board. Cardiac MRI and right heart catheterization were conducted before BPA sessions and at the follow up after BPA in 20 patients with CTEPH. We measured right ventricular (RV) and left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) using MRI. For the LV and RV free walls, the time to peak (Tpeak) of circumferential strain was calculated as a parameter for interventricular dyssynchrony. Following BPA, the RV-EDV and -ESV were significantly decreased, and the RVEF was significantly increased. Conversely, BPA led to significantly increased LV EDV and SV without changing LVESV. The left-to-right free wall delay (L–R delay) in Tpeak strain decreased from 105 ± 44 ms to 47 ± 67 ms (p

We report on a 57-year-old man with atrial tachycardia mimicking inappropriate sinus tachycardia that was sustained for 4 months despite pharmacotherapy. Using a noncontact mapping system (EnSite Array), the atrial earliest activation (EA) site was identified during tachycardia. By infusing the β1 antagonist landiolol and the β1 agonist isoproterenol, we varied his heart rate from 110 to 155 beats per minute. As his heart rate increased, the EA site moved from the top of the right atrial septum near the crist a terminalis to the right atrial append age (RAA). Tachycardia was terminated by multiple applications of radiofrequency catheter ablation to the RAA. Because the EA site of the sinus rhythm was distant from the ablation points, the tachycardia was diagnosed as persistent atrial tachycardia with multiple foci in a broad area around the RAA. On 12-lead electrocardiogram, the P-wave morphology in leads V1 and V2 changed from negative to positive upon termination of tachycardia.

We herein report the case of 34-year-old woman with acute tricuspid valve infective endocarditis (IE) associated with a ruptured sinus of Valsalva and multiple septic pulmonary emboli. She had no history of medical problems, except for atopic dermatitis (AD). Blood cultures identified methicillin-sensitive Staphylococcus aureus. Despite the administration of two months of antibiotic therapy, the patient experienced recurrent pulmonary emboli and developed heart failure due to a left-to-right shunt, whereas the area of vegetation did not change in size. She subsequently underwent surgery for shunt closure and tricuspid valve replacement. The AD was thought to be the cause of the patient's bacteremia, which consequently resulted in aggressive right-sided IE.

A 60-year-old man with inoperable chronic thromboembolic pulmonary hypertension was referred to our hospital for balloon pulmonary angioplasty (BPA). Four series of BPA dramatically improved pulmonary hypertension: mean pulmonary arterial pressure from 42 to 29 mm Hg and cardiac index from 1.9 to