QuestionDoes achieving guideline-recommended low-density lipoprotein cholesterol (LDL-C) levels help prevent neoatherosclerosis after drug-eluting stent implantation in patients with ST-segment elevation myocardial infarction (STEMI)?FindingsIn this secondary analysis of the CONNECT randomized clinical trial, neoatherosclerosis was less frequent in patients who achieved guideline-endorsed LDL-C levels and received high-intensity statin therapy. On-treatment LDL-C level emerged as an independent determinant of neoatherosclerosis.MeaningAchieving guideline-recommended LDL-C levels through intensive lipid-lowering therapy may help prevent neoatherosclerosis formation and prevent late stent failure in patients with STEMI. ImportanceNeoatherosclerosis represents a major cause of late stent failure and results in cardiac events after drug-eluting stent (DES) implantation. Achieving secondary preventive low-density lipoprotein cholesterol (LDL-C) target levels can reduce plaque progression in native coronary arteries; however, its association with neoatherosclerosis formation remains unclear.ObjectiveTo determine whether achieving guideline-endorsed LDL-C levels after DES implantation is associated with reduced risk of long-term neoatherosclerosis formation.Design, Setting, and ParticipantsThis is a post hoc analysis of the CONNECT randomized clinical trial conducted at 7 sites in Switzerland and Japan that had randomized 239 patients with ST-segment elevation myocardial infarction (STEMI) to percutaneous coronary intervention (PCI) with biodegradable- or durable-polymer everolimus-eluting stents between June 2017 and June 2020. The prevalence of neoatherosclerosis was assessed with optical coherence tomography (OCT) 3 years after primary PCI. Data analysis for this post hoc analysis was conducted from September 2024 to October 2025.InterventionPatients with STEMI received primary PCI with DES, and statin therapy was recommended according to country-specific guidelines.Main Outcomes and MeasuresThe prevalence of neoatherosclerosis 3 years after primary PCI was compared between patients with vs without achievement of guideline-endorsed target LDL-C levels. A multivariable predictor analysis was performed to determine whether on-treatment LDL-C levels were associated with occurrence of neoatherosclerosis.ResultsAmong 178 patients (mean [SD] age, 63.4 [10.9] years; 27 [15%] female) who underwent OCT at 3 years, 98 patients (55%) achieved the target LDL-C level and 80 patients (45%) did not. The mean (SD) on-treatment LDL-C levels for these groups were 48 (13) and 87 (37) mg/dL, respectively (to convert to millimoles per liter, multiply by 0.0259). The prevalence of neoatherosclerosis was lower in patients who achieved the target LDL-C level as compared with patients who did not (7 patients [7%] vs 15 patients [19%], respectively; odds ratio for those who did not achieve the LDL-C target level, 3.00; 95% CI, 1.19-8.24; P = .02). On-treatment LDL-C level (per 25-mg/dL increase) emerged as an independent determinant of neoatherosclerosis at 3 years in multivariable logistic regression analysis (odds ratio, 1.46; 95% CI, 1.09-2.01; P = .01).Conclusions and RelevanceOn-treatment LDL-C level emerged as an independent predictor of neoatherosclerosis 3 years after DES implantation for STEMI. Neoatherosclerosis was less frequent among patients who achieved the guideline-recommended on-treatment LDL-C level, underscoring the importance of LDL-C lowering in preventing neoatherosclerosis formation.Trial RegistrationClinicalTrials.gov Identifier: NCT03440801 This secondary analysis of the CONNECT randomized clinical trial evaluates whether achieving a guideline-endorsed low-density lipoprotein cholesterol level after drug-eluting stent implantation in patients with ST-segment elevation myocardial infarction (STEMI) is associated with reduced risk of long-term neoatherosclerosis formation.

Epicardial ablation is an increasingly important treatment for refractory ventricular tachycardia (VT), particularly in nonischemic cardiomyopathy or when the substrate is epicardial or mid-myocardial. This review provides an overview of the pathophysiology and disease-specific characteristics of VT substrates, with a particular focus on epicardial involvement and indications based on electrocardiographic, imaging, and clinical findings. We present advanced substrate-mapping strategies, including functional and high-resolution approaches, and practical examples of three-dimensional mapping using the CARTO™ (Biosense Webster, Diamond Bar, CA, USA) and EnSite™ (Abbott, Abbott Park, IL, USA) systems to overcome the known limitations of conventional mapping techniques. In the latter part of the review, we discuss the technical aspects of epicardial access, as well as the clinical challenges and strategies for challenging scenarios, such as bipolar ablation and ablation after prior cardiac surgery, supported by practical examples from our institution. We also highlight future perspectives. These insights are expected to contribute to the optimization of treatment strategies for refractory epicardial VT and to support the development of more precise and durable patient care.

BACKGROUND:Although sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recommended for patients with diabetes mellitus (DM) and peripheral artery disease (PAD), their effects on limb-related outcomes remain uncertain, and their use after peripheral endovascular therapy (EVT) yields suboptimal outcomes. This study was to evaluate the prognostic impact of SGLT2i use in patients undergoing EVT for symptomatic PAD. METHODS:We retrospectively analyzed 470 PAD and DM patients (without end-stage renal disease) who underwent successful EVT between September 2016 and July 2022, categorizing them as SGLT2i users (n = 99) or non-users (n = 371). The primary endpoint was major adverse cardiovascular events (MACE: all-cause death, myocardial infarction, or stroke), and the secondary endpoint was limb-level major adverse limb events (L-MALE: repeat revascularization or major amputation for the target limb). Propensity score matching was performed. RESULTS:During a median follow-up of 4.0 years (interquartile range, 2.3-5.6), 115 MACE (100 deaths, 14 myocardial infarctions, 16 strokes) and 131 L-MALE (94 target-lesion revascularizations, 7 major amputations) occurred. Freedom from MACE was significantly higher in SGLT2i users than non-users (77.2% vs. 67.1%; p = 0.023), whereas freedom from L-MALE did not significantly differ between the two groups (52.8% vs. 57.5%; p = 0.59). These associations remained consistent across advanced age, frailty, and chronic limb-threatening ischemia (CLTI), heart failure (HF), and overweight status (all interactions p > 0.05). CONCLUSIONS:In PAD and DM patients after successful EVT, SGLT2i use was linked to lower MACE risk without increased L-MALE, irrespective of age, frailty, CLTI, HF, and overweight status.

Background: Chronic kidney disease is associated with an increased incidence of stent thrombosis (ST) following drug-eluting stent (DES) implantation, but the clinical outcomes after DES-ST in hemodialysis (HD) patients compared with non-HD patients have not been fully elucidated. Methods and Results: From the REAL-ST registry, we evaluated 655 patients with DES-ST, divided into 2 groups: HD group (n=59) and non-HD group (n=596). The primary endpoint was the cumulative 3-year incidence of all-cause death after the index ST event. Late ST was more prevalent in the HD group, whereas early and very late ST were common in the non-HD group. Following the index ST event, the HD group showed significantly higher 3-year incidences of all-cause death (48.2% vs. 22.9%, P=0.0005), cardiac death (33.4% vs.15.8%, P=0.003) and target lesion revascularization (TLR: 36.2% vs. 17.5%, P=0.0002) compared with the non-HD group. The cumulative 3-year incidence of recurrent ST did not differ significantly between groups (7.3% vs. 5.9%, P=0.88). After multivariable adjustment, HD remained significantly associated with an increased risk of all-cause death (adjusted hazard ratio [aHR], 1.95; 95% confidence interval [CI], 1.25-3.04; P=0.003), cardiac death (aHR, 1.75; 95% CI, 1.02-2.99; P=0.04) and TLR (aHR, 2.63; 95% CI, 1.52-4.57; P<0.001). Conclusions: Compared with non-HD patients, HD patients experienced worse clinical outcomes following their index DES-ST event.

The success of drug-coated balloon (DCB) therapy for de novo coronary lesions relies on optimal lesion preparation. However, evidence supporting the use of cutting balloons (CBs) for lesion preparation in DCB-only strategies remains limited. The NATURE trial assessed the effectiveness of CB compared with standard balloon (SB) predilatation in achieving optimal lesion preparation for a DCB-only strategy. The NATURE trial was a prospective, multicentre, randomised study conducted at 19 Japanese centres. Patients with de novo coronary lesions suitable for a DCB-only strategy were randomised (1:1) to lesion preparation with CB or SB. Post-predilatation assessment included coronary angiography, intravascular ultrasound (IVUS), and fractional flow reserve (FFR). The primary endpoint was optimal lesion preparation, defined as the simultaneous presence of: (1) no flow-limiting dissection, (2) residual diameter stenosis ≤ 30 This central illustration summarises the study design, procedural workflow, and key findings of the NATURE trial. Patients with de novo coronary lesions were randomised to lesion preparation with a cutting balloon or a standard balloon before a drug-coated balloon (DCB)–only strategy. Multimodality assessments using quantitative coronary angiography (QCA) and fractional flow reserve (FFR) were performed serially from pre–percutaneous coronary intervention through post-predilatation and post-DCB treatment, and intravascular ultrasound (IVUS) was performed after predilatation. The primary endpoint—achievement of optimal lesion preparation defined as the absence of flow-limiting dissection, residual diameter stenosis ≤ 30

BACKGROUND:Changes in N-terminal pro B-type natriuretic peptide (NT-proBNP) levels and cardiac remodeling from baseline to follow-up in patients with heart failure with reduced ejection fraction (HFrEF) treated with vericiguat remain unclear. METHODS AND RESULTS:The VERIFY-HF registry is a nationwide multicenter retrospective single-arm study of patients with HFrEF newly prescribed vericiguat at 22 hospitals in Japan. In this study, we analyzed baseline and follow-up echocardiography findings of 504 patients. Vericiguat dose-dependently reduced NT-proBNP levels, with a greater reduction in those receiving 7.5 or 10 than ≤5 mg vericiguat (NT-proBNP least-squares geometric mean ratio [3 months/baseline] 0.53 vs. 0.65, respectively; P=0.009). Multivariable analysis revealed that high-dose (7.5 or 10 mg) vericiguat was independently associated with a greater reduction in log-transformed NT-proBNP at 3 months (β=-0.125; 95% confidence interval [CI] -0.247, -0.004; P=0.043). High-dose vericiguat was not significantly associated with changes in left ventricular ejection fraction (LVEF) at 12 months (β=0.53; 95% CI -0.49, 1.6; P=0.30). Overall, reverse remodeling at 12 months was modest (LVEF, +4.7%; left ventricular end-systolic volume index, -6.4 mL/m2) and was predominantly associated with newly initiated β-blockers or renin-angiotensin system inhibitors within 3 months prior to vericiguat administration or prior heart failure hospitalization rather than vericiguat dose. CONCLUSIONS:In this real-world registry study, high-dose vericiguat was associated with sustained dose-dependent reductions in NT-proBNP, but not cardiac reverse remodeling.

BACKGROUND:Adherence to the clinical performance measures has been advocated in ST-segment-elevation acute myocardial infarction (STEMI) care worldwide. We aimed to examine the association between adherence to these performance measures and long-term clinical outcomes in patients with STEMI undergoing percutaneous coronary intervention. METHODS:The CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) AMI Registry Wave-2 was a multicenter registry conducted at 22 centers in Japan between 2011 and 2013, enrolling consecutive acute myocardial infarction patients who underwent coronary revascularization. The exposures were adherence to 9 guideline-based performance measures for STEMI care, including early reperfusion, evidence-based medical therapy, and cardiac rehabilitation. The primary outcome measure was all-cause death. The secondary outcome measures included cardiovascular death, myocardial infarction, stroke, heart failure hospitalization, major bleeding, and repeat coronary revascularization. Outcomes were assessed over a median follow-up of 6.0 years (interquartile range, 5.1-6.8). Adjusted hazard ratios with 95% CIs were estimated using Cox proportional hazards models, adjusting for baseline characteristics. RESULTS:Among 2892 patients with STEMI who underwent percutaneous coronary intervention within 24 hours after symptom onset and survived to discharge (mean age, 67±13 years; 23% women), patients were categorized according to the number of fulfilled performance measures (PMs=9: N=551, PMs=8: N=985, PMs=7: N=794, and PMs≤6: N=562). As the adherence categories decreased from PMs=9 to PMs≤6, the cumulative 5-year incidence of all-cause death increased from 8.9% to 23.6%. Relative to PMs=9, the adjusted hazard ratio (95% CI) for all-cause death was 1.14 (0.83-1.57) in PMs=8, 1.36 (0.99-1.87) in PMs=7, and 1.96 (1.43-2.69) in PMs≤6, respectively. These inverse associations were observed between adherence to performance measures and most clinical outcomes except for repeat coronary revascularization (adjusted hazard ratio, 1.00 [95% CI, 0.82-1.21] in PMs=8, 0.89 [0.72-1.09] in PMs=7, and 0.91 [0.72-1.15] in PMs≤6, respectively). CONCLUSIONS:Defect-free care adherent to the performance measures was associated with improved long-term clinical outcomes, including lower mortality, among patients with STEMI undergoing percutaneous coronary intervention, whereas no association was observed for repeat coronary revascularization.

CASE SUMMARY:Transcarotid-transcatheter aortic valve implantation (TC-TAVI) generally enables smooth transcatheter heart valve crossing given its proximity to the aortic annulus; however, severe anatomical constraints may still lead to delivery failure. We report a TC-TAVI case in which transcatheter heart valve passage across the aortic valve was initially unsuccessful because of aortic angulation and extensive leaflet calcification. This technical difficulty was effectively resolved using the buddy balloon technique, which enabled successful valve advancement. This case demonstrates that the superior pushability of the TC approach may not overcome extreme anatomical resistance, necessitating predilatation aggressively indicated for such challenging anatomies. TAKE-HOME MESSAGES:Pronounced aortic angulation and severe leaflet calcification can hinder transcatheter heart valve delivery, even during TC-TAVI, where easier valve crossing is typically anticipated. These anatomical factors remain significant predictors of delivery failure, irrespective of the vascular access route.

AIMS:The relief of the symptoms is one of the major purposes in the treatment for acute decompensated heart failure. The aim of this study is to investigate the relationship between patient-reported perception of symptom change of heart failure during hospitalization and subsequent prognosis in patients with acute decompensated heart failure (ADHF). METHODS AND RESULTS:Among 4056 consecutive patients hospitalized due to ADHF from a multicentre cohort study in Japan (Kyoto Congestive Heart Failure study), the study population consisted of 3567 patients who assessed their perception of symptom change during index hospitalization by themselves on 7-point Likert scale. We classified them the study patients into 4 groups: marked improvement group (N = 1602; 44.9%), moderate improvement group (N = 1659; 46.5%), minimal improvement group (N = 240; 6.7%), and no improvement group (N = 66; 1.9%). Primary outcome measures were a composite of all-cause death or HF hospitalization. The cumulative 1-year incidence of the primary outcome was higher in the no, minimal, and moderate improvement groups than in the marked improvement group (56%, 45%, 36%, vs. 29%, log-rank P < 0.001). After adjustment, the hazard ratios of the no, minimal, and moderate improvement groups relative to the marked improvement group were 1.66, 95% confidence interval [CI]: 1.14-2.42; 1.26, 95% CI: 1.01-1.57; 1.08, 95% CI: 0.95-1.21, respectively, for the primary outcome. CONCLUSION:The patient-reported perception of symptom change at discharge was correlated with a composite of all-cause death or HF hospitalization at 1 year after discharge in patients admitted to the hospital for ADHF.

Background The restrictive filling pattern of transmitral inflow has been shown to be associated with a poor prognosis in patients with heart failure (HF) with reduced ejection fraction or myocardial infarction. We aimed to investigate the significance of restrictive filling pattern in patients with HF with preserved ejection fraction (HFpEF).Methods Among 4056 patients with acute decompensated HF in the Kyoto Congestive Heart Failure registry, we analysed 830 patients with HFpEF who had transmitral inflow data available in echocardiography. Patients whose early to late diastolic transmitral flow velocity (E/A ratio) ≥2 were classified as having a restrictive filling pattern of transmitral inflow. The main outcome measures were all-cause death and HF hospitalisation at 1 year.Results Among 830 patients, a restrictive filling pattern was observed in 144 (17.3%) patients, who had higher prevalence of a history of atrial fibrillation and supranormal left ventricular ejection fraction (>65%), and higher brain natriuretic peptide level at discharge. The cumulative 1-year incidence of HF hospitalisation was significantly higher in patients with restrictive filling pattern than those without (31.0% vs 18.1%, p<0.001), while the cumulative 1-year incidence of all-cause death was not different between the two groups (14.2% vs 14.4%, p=0.93). After adjusting for confounding factors, the excess risk of restrictive filling pattern relative to non-restrictive filling pattern remained significant for HF hospitalisation (HR=1.58, 95% CI 1.10 to 2.27, p=0.01), but not for all-cause death (HR=0.92, 95% CI 0.60 to 1.42, p=0.70).Conclusions A restrictive filling pattern of transmitral inflow was associated with an increased risk for HF hospitalisation, but not for all-cause death, in patients with acute decompensated HFpEF.

Importance:Neoatherosclerosis represents a major cause of late stent failure and results in cardiac events after drug-eluting stent (DES) implantation. Achieving secondary preventive low-density lipoprotein cholesterol (LDL-C) target levels can reduce plaque progression in native coronary arteries; however, its association with neoatherosclerosis formation remains unclear. Objective:To determine whether achieving guideline-endorsed LDL-C levels after DES implantation is associated with reduced risk of long-term neoatherosclerosis formation. Design, Setting, and Participants:This is a post hoc analysis of the CONNECT randomized clinical trial conducted at 7 sites in Switzerland and Japan that had randomized 239 patients with ST-segment elevation myocardial infarction (STEMI) to percutaneous coronary intervention (PCI) with biodegradable- or durable-polymer everolimus-eluting stents between June 2017 and June 2020. The prevalence of neoatherosclerosis was assessed with optical coherence tomography (OCT) 3 years after primary PCI. Data analysis for this post hoc analysis was conducted from September 2024 to October 2025. Intervention:Patients with STEMI received primary PCI with DES, and statin therapy was recommended according to country-specific guidelines. Main Outcomes and Measures:The prevalence of neoatherosclerosis 3 years after primary PCI was compared between patients with vs without achievement of guideline-endorsed target LDL-C levels. A multivariable predictor analysis was performed to determine whether on-treatment LDL-C levels were associated with occurrence of neoatherosclerosis. Results:Among 178 patients (mean [SD] age, 63.4 [10.9] years; 27 [15%] female) who underwent OCT at 3 years, 98 patients (55%) achieved the target LDL-C level and 80 patients (45%) did not. The mean (SD) on-treatment LDL-C levels for these groups were 48 (13) and 87 (37) mg/dL, respectively (to convert to millimoles per liter, multiply by 0.0259). The prevalence of neoatherosclerosis was lower in patients who achieved the target LDL-C level as compared with patients who did not (7 patients [7%] vs 15 patients [19%], respectively; odds ratio for those who did not achieve the LDL-C target level, 3.00; 95% CI, 1.19-8.24; P = .02). On-treatment LDL-C level (per 25-mg/dL increase) emerged as an independent determinant of neoatherosclerosis at 3 years in multivariable logistic regression analysis (odds ratio, 1.46; 95% CI, 1.09-2.01; P = .01). Conclusions and Relevance:On-treatment LDL-C level emerged as an independent predictor of neoatherosclerosis 3 years after DES implantation for STEMI. Neoatherosclerosis was less frequent among patients who achieved the guideline-recommended on-treatment LDL-C level, underscoring the importance of LDL-C lowering in preventing neoatherosclerosis formation. Trial Registration:ClinicalTrials.gov Identifier: NCT03440801.

Introduction Epicardial adipose tissue (EAT) can attenuate electrograms and limit lesion formation during epicardial ventricular tachycardia (VT) ablation. Case Presentation We developed a simplified workflow using predefined CT attenuation values to integrate EAT into the CARTO 3 system. We applied this approach in three patients with dilated cardiomyopathy undergoing epicardial VT ablation, where EAT visualization guided target selection, avoided ineffective ablation, and informed alternative endocardial strategies. Discussion EAT-integrated mapping improved the interpretation of epicardial substrates and influenced procedural decision-making. This workflow may facilitate efficient assessment of epicardial ablation feasibility in complex VT cases.

The clinical trials in low risk patients have clearly demonstrated clinical outcomes of transcatheter aortic-valve replacement (TAVR) comparable to those of surgical aortic-valve replacement (SAVR) in patients with severe aortic stenosis (AS). However, data are lacking on the appropriate treatment selection for patients with severe AS and low surgical risk in Japanese routine clinical practice. Among 3369 patients enrolled in the CURRENT AS Registry-2 between April 2018 and December 2020, the current study population include 826 patients with low Society of Thoracic Surgeons (STS) score and not on hemodialysis who actually underwent TAVR (439 patients) or SAVR (387 patients). After propensity score matching, there remained 162 patients in each group. The primary outcome was a composite of all-cause death, disabling stroke, or heart failure hospitalization. The cumulative 3-year incidence of the primary outcome was not significantly different between the TAVR and SAVR groups (19.5

Combination therapy with atherectomy and intravascular lithotripsy (IVL) has emerged as a promising strategy for the treatment of severely calcified occlusive coronary lesions, which potentially enhances procedural efficacy without increasing complication risk. The Dual-Prep Registry is a multicenter, prospective registry designed to evaluate the safety and efficacy of IVL after atherectomy in severely calcified lesions. Combined use was selectively applied when the risk of complications was anticipated to be high with a larger atherectomy burr size, or when it was deemed non-beneficial due to unfavorable guidewire bias. All adverse events were adjudicated by a clinical events committee. Kaplan–Meier analysis was performed to evaluate the primary endpoint of major adverse cardiovascular events (MACE; composite endpoint of cardiac death, myocardial infarction, and target vessel revascularization [TVR]) at 1 year. A total of 118 cases (120 lesions) were enrolled across 20 facilities. Significant comorbidities included diabetes in 56.8 https://jrct.mhlw.go.jp .