Background Immune checkpoint inhibitors (ICIs) can cause cardiac immune-related adverse events (irAEs), including pericarditis. Cardiovascular events related to pericardial irAE are less frequent, but fulminant forms can be fatal. However, the diagnosis and treatment strategies for pericardial irAE have not established. Case summary A 58-year-old man was diagnosed with advanced non-small-cell lung cancer and nivolumab was administered as 5th-line therapy. Eighteen months after the initiation of nivolumab, the patient developed limb oedema and increased body weight. Although a favourable response of the cancer was observed, pericardial thickening and effusion were newly detected. He was diagnosed with irAE pericarditis after excluding other causes of pericarditis. Nivolumab was suspended and a high-dose corticosteroid was initiated. However, right heart failure (RHF) symptoms were exacerbated during the tapering of corticosteroid because acute pericarditis developed to steroid-refractory constrictive pericarditis. To suppress sustained inflammation of the pericardium, infliximab, a tumour necrosis factor-alfa inhibitor, was initiated. After the initiation of infliximab, the corticosteroid dose was tapered without deterioration of RHF. Exacerbation of lung cancer by irAE treatment including infliximab was not observed. Discussion IrAE should be considered when pericarditis develops after the administration of ICI even after a long period from its initiation. Infliximab rescue therapy may be considered as a 2nd-line therapy for steroid-refractory irAE pericarditis even with constrictive physiology.

Background Venous thromboembolism (VTE) is highly associated with advanced gastric cancer (AGC) and is sometimes lethal. Predictors of VTE have not been identified, and the efficacy and safety of direct oral anticoagulants (DOACs) for AGC-associated VTE remain to be clarified. Methods A total of 188 AGC patients who started chemotherapy during the period from January 2014 to December 2017 in our institutions were retrospectively examined for the incidence of VTE, risk factors for VTE, and the efficacy and safety of DOAC-based anticoagulant therapy for VTE. Results Thirty-four patients (18%) were diagnosed with VTE at the start or during the course of chemotherapy (VTE group). More VTE group patients had a history of abdominal surgery and had moderate-severe ascites (32% versus 17%, 32% versus 14%, respectively) than non-VTE group patients (NVTE group). The mean serum albumin concentrations in the VTE group were significantly lower than NVTE group (3.38 mg/dL vs 3.65 mg/dL, respectively). Multivariate analysis showed that hypoalbuminemia was significantly correlated with VTE (P = 0.012). In the VTE group, 29 patients (85%) received anticoagulant therapy, including 24 patients treated with DOACs. No lethal VTE was observed in any patients. Thirteen patients (45%) terminated DOACs because of anemia or bleeding events, of whom eleven developed major bleeding. Median overall survivals of the VTE and NVTE groups were 9.63 months and 11.5 months, respectively (P = 0.262). Conclusion Hypoalbuminemia appears to be a risk factor for AGC-associated VTE. DOACs are effective to AGC-associated VTE, but careful observation of bleeding events is required.

Our results revealed that the major differences between ADD and DHF were global and longitudinal LV systolic dysfunction and LV enlargement. This study suggests that LV systolic dysfunction plays an important role in the development of DHF.

Preoperative appearance of anti-p53 antibody in sera can be correlated with the incidence of triple negative breast cancer and could therefore help identify tumors with aggressive potential.

Background/Aim: Pancreatic surgery is associated with a high risk of developing deep venous thrombosis (DVT) and malnutrition. We aimed to evaluate the factors predicting the development of DVT, focusing on nutrition assessment tools. Patients and Methods: One hundred patients who underwent pancreatic surgery were postoperatively examined for DVT. We assessed the risk factors for the development of DVT after surgery. Results: Postoperative DVT was detected in 11 patients (11%). Patients who developed DVT after surgery were significantly older (p=0.016) and had higher preoperative D-dimer levels (p=0.005) than those who did not. The preoperative prognostic nutritional index (PNI) was mostly associated with the development of DVT (p=0.079). Furthermore, PNI ≤44.3, BUN >20 mg/dl, D-dimer ≥1.9 μg/ml were independent predictors for the development of DVT after surgery. Conclusion: A poor nutrition status and dehydration should be preoperatively improved for patients who are identified, as having a high risk of developing DVT after pancreatic surgery.

A 68-year-old woman was admitted to our hospital because of back pain and syncope. Transthoracic echocardiography revealed pericardial effusion, a collapsed right ventricle, a giant aneurysm connected to the coronary sinus, a dilated left main trunk coronary artery, and a dilated left circumflex artery (LCx). Furthermore, there was a coronary artery fistula arising from the LCx that drained into the coronary sinus. We diagnosed cardiac tamponade due to rupture of the coronary artery fistula or giant aneurysm, and successful emergency surgery was performed. Rupture of coronary artery aneurysm or coronary artery fistula is very rare. Transthoracic two-dimensional echocardiography was very useful in our case for the diagnosis of cardiac tamponade, giant coronary aneurysm, and coronary artery fistula.

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp ssential hypertension is a major risk factor for cardiovascular disease. In hypertensive patients, pressure and/or volume overload leads to left ventricular (LV) hypertrophy, which is a powerful independent predictor of morbidity and mortality. 1 Hypertensive LV hypertrophy causes heart failure, especially diastolic heart failure, which is heart failure with a normal LV ejection fraction (LVEF) because of LV diastolic dysfunction. However, several studies have reported that patients with diastolic heart failure have not only diastolic dysfunction but also systolic dysfunction, when parameters other than LVEF were used to evaluate systolic function. 2-5 Therefore, global cardiac function including systolic and diastolic LV function should be evaluated by non-conventional functional parameters such as the Tei index. The Tei index, combining systolic and diastolic functional parameters, may be a better and simpler parameter to estimate LV global function than conventional indices of purely systolic or diastolic function in hypertensive patients.Based on LV mass and relative wall thickness, patients with essential hypertension can be classified into 4 different LV geometric patterns: normal, concentric remodeling, concentric hypertrophy and eccentric hypertrophy. 6-8 Previous studies have reported that abnormal LV geometric patterns are associated with a greater risk of hypertensive complications, and patients with concentric LV hypertrophy have the highest mortality and cardiovascular event rate. 7,9 The relation between these 4 different LV geometric patterns and LV function has not been elucidated. Therefore, we aimed to investigate the correlation Background: Left ventricular (LV) hypertrophy is a powerful independent predictor of morbidity and mortality in hypertensive patients. Abnormal LV geometric patterns are also associated with hypertensive complications, and concentric hypertrophy is associated with the highest mortality in hypertensive patients. However, the relationship between geometric patterns and cardiac dysfunction is not fully established. We hypothesized that the Tei index, which is a measure of global cardiac function, is a feasible parameter for estimating cardiac dysfunction among the different LV geometric patterns in hypertensive patients. E

SummarySjogren's syndrome (SS) is an autoimmune disease characterized by dryness of the mouth and the eyes. Systemic involvement in SS is well known, however, obvious cardiac manifestations, particularly significant valve disorders, are extremely rare and only three cases of significant valve disease associated with SS that required surgical intervention have been previously described. We report a case of aortic stenosis (AS) associated with SS in an elderly patient. The diagnosis of primary SS had been made based on clinical features, positive ocular signs, and positive serologic findings. Echocardiography showed severe calcification, elevated mean pressure gradient (57 mmHg), and a small orifice area (0.45 cm 2 ) of the aortic valve. At surgery, severe calcification of the aortic cusps and the annulus was the mechanism of AS, and the aortic valve was replaced with a bioprosthetic valve. Valve pathology showed nodular calcification and hyaline degeneration, but lymphocyte infiltration was not evident. The etiologic relation of SS to the valve lesions is not clear pathologically in this case, however, chronic inflammation related to immunologic reactions in SS could have some effect on exacerbation for degeneration of the valve tissue. (Int Heart J 2016; 57: 251-253) Key words: Autoimmune disease, Bioprosthetic valve, Heart valve disease, Mechanical valve, Valve replacement S jogren's syndrome (SS) is an autoimmune disease characterized by keratoconjunctivitis sicca (dry eye) and xerostomia (dry mouth) that is the result of lymphocyte-mediated destruction of exocrine glands, and mostly affects middle-aged women. The systemic manifestations of SS such as articular, lung, kidney, vascular, and gastrointestinal involvement are well known, however, obvious cardiac manifestations are rare, although clinically silent involvements are fairly common on echocardiography.1) To our knowledge, only a few cases of clinically significant cardiac valve disease associated with SS that required surgical intervention have been described in the literature. 2-4)In this paper, we report a case of aortic stenosis (AS) associated with SS, and discuss prosthetic valve selection in valve surgery for patients associated with an autoimmune disorder.The current study was approved by our institutional Research Ethics Board at the Munakata Suikokai General Hospital, and written informed consent was obtained from the patient for publication of this case report and any accompanying images. Case ReportA 70-year-old woman was admitted to our hospital for nocturnal dyspnea and chest pain. She had never smoked and had no history of rheumatic fever or diabetes mellitus, but she was on medication for hypertension and dyslipidemia for more than 10 years. At the age of 66 the patient had been diagnosed with Castleman's disease (hyaline-vascular type) after lymph node biopsy, and primary SS based on clinical features (dry mouth and eyes), ocular signs (a Shirmer's test; ≤ 3 mm in 5 minutes, rose Bengal score ≥ 4), and serological findings ( Table).5...