Renal dysfunction is a simple but useful means of predicting complications in hospitalized patients with takotsubo syndrome, especially those with chronic kidney disease.

Background: Current guidelines recommend dual antiplatelet therapy for the first 1 to 6 months after transcatheter aortic valve replacement (TAVR); however, recent studies have reported better outcomes with single antiplatelet therapy than with dual antiplatelet therapy in the occurrence of bleeding events, while not increasing thrombotic events. However, no data exist about optimal single antiplatelet therapy following TAVR. Methods: Patients who underwent TAVR between October 2013 and May 2017 were enrolled from the OCEAN-TAVI Japanese multicenter registry (Optimized Transcatheter Valvular Intervention). After excluding 1759 patients, 829 who received aspirin (100 mg/d) or clopidogrel (75 mg/d) after TAVR were identified and stratified according to the presence or absence of anticoagulation. Propensity score matching was performed to adjust the baseline characteristics between the aspirin and clopidogrel groups. Outcomes of interest were all-cause and cardiovascular deaths, stroke, and life-threatening or major bleeding within 2 years following TAVR. Results: After propensity score matching, 98 and 157 pairs of patients without and with anticoagulation, respectively, were identified. Falsification end points of pneumonia, urinary tract infection, and hip fracture were evaluated, and their rates were not different between groups. All-cause deaths were not statistically different between the groups in patients with (aspirin, 17.5%; clopidogrel, 11.1%; log-rank P =0.07) and without (aspirin, 29.6%; clopidogrel, 20.1%; log-rank P =0.15) anticoagulation at 2 years post-TAVR, whereas clopidogrel was associated with a lower cardiovascular mortality at 2 years in patients with (aspirin, 8.5%; clopidogrel, 2.7%; log-rank P =0.03) and without (aspirin, 18.0%; clopidogrel, 5.2%; log-rank P =0.02) anticoagulation. Conclusions: We demonstrated that clopidogrel monotherapy was associated with a lower incidence of cardiovascular death compared with aspirin monotherapy during the 2-year follow-up after TAVR regardless of anticoagulation use. Registration: URL: https://upload.umin.ac.jp ; Unique identifier: UMIN000020423.

Background Subclinical leaflet thrombosis, characterized by hypoattenuated leaflet thickening (HALT) on multidetector computed tomography, is common after transcatheter aortic valve replacement (TAVR). Because little is known about the long‐term natural history of subclinical HALT, we aimed to investigate this in patients who underwent TAVR without using additional anticoagulation. Methods and Results We retrospectively evaluated patients who underwent TAVR with the Edwards SAPIEN‐XT at our institute between October 2013 and December 2015. Patients were grouped according to the presence or absence of HALT within 1 year after TAVR (HALT and No‐HALT groups). The primary outcome, defined as the composite of all‐cause mortality, heart failure readmission, and ischemic stroke, was compared. Valve performance was assessed over time by transthoracic echocardiography. Among 124 patients (men: 29.1%; median age, 85 years), 27 (21.8%) showed HALT on multidetector computed tomography within 1 year after TAVR. No patient required additional anticoagulation for treating HALT because of the absence of valve‐related symptomatic deterioration. During the median follow‐up period of 4.7 years (interquartile range, 4.0–5.6), the rate of primary outcome and valve performance was not statistically different between the 2 groups (37.0% versus 38.1%; log‐rank test P =0.92; mean pressure gradient, 9 mm Hg [8–14 mm Hg] versus 10 mm Hg [7–15 mm Hg]; P =0.51, respectively). Conclusions Approximately 20% of patients after TAVR had HALT within 1 year; however, that did not change the risk of subsequent adverse cardiovascular events or the valve performance with statistical significance for up to 5 years despite no additional anticoagulation therapy.

A 77-year-old man with liver cirrhosis was admitted to our hospital in 2015. He was unconscious and his Glasgow Coma Scale (GCS) score was 10. The Hb level was 3.5 mg/ dL. Contrast CT showed esophageal varices and atrophy of liver, these findings indicated a suspicion of liver cirrhosis. We considered that the varix rupture and the resulting hemorrhagic shock were the main cause of the patient's unconsciousness. We performed gastroduodenoscopy, leading to endoscopic variceal ligation (EVL) of the two varices. The procedure ended successfully, and the patient returned to the ER.Shortly after returning to the ER, the patient suddenly became unresponsive. His GCS score dropped to 7. Head CT showed pneumocephalus and a suspected air embolism of the right hemisphere (Left Picture). Hyperbaric oxygen therapy was performed seven times, but his GCS did not improve above 9. CT on day 40 showed a massive infarction of the right hemisphere. (Right Picture). In this case, the patient fortunately survived, but he was left with major disabilities and was no longer independent. Transthoracic echocardiography did not show any evidence of a patent foramen ovale. The mechanism of air embolism after EVL remains to be elucidated, but mucosal damage realted to invasive endoscopic procedures is thought to be the major cause of air embolism.We obtained the patient's informed consent to conduct this study.The author states that he has no Conflict of Interest (COI).

Lindman et al 3 reported that after adjustment for right ventricle (RV) dysfunction (RVD), significant TR was independently associated with increased mortality. In contrast, in other studies, RVD, rather than significant TR, led to adverse outcomes. 2,4 As stated by Bolling, the association between RV function and TR is complex and intertwined. 6 In considering the management of AS with TR, we thought it important to clarify the relationship between the etiology of TR, RVD, and prognosis. Therefore, the aim of this study was to investigate: (1) the clinical impact of con-A lthough the tricuspid valve (TV) has long been regarded as the "forgotten" valve of the heart patients with untreated tricuspid regurgitation (TR) have recently been found to have a poor prognosis. 1 In patients with severe aortic stenosis (AS), concomitant significant TR may appear in approximately 10-30% of cases. 2-4 Guidelines suggest repairing significant TR when left-sided heart surgery is performed. 5 However, with the arrival of TAVI, new problems have arisen because these patients are unable to undergo concomitant tricuspid surgery.Recently, many studies have focused on the role of con-