Background: Postoperative development of aortic insufficiency (AI) after implantation of left ventricular assist devices (LVADs) has recently been recognized, but the devices in the previous reports have been limited to the HeartMate I or II. The purposes of this study were to determine whether AI develops with other types of LVADs and to elucidate the factors associated with the development of AI. Methods and Results: Thirty-seven patients receiving LVADs without evident abnormalities in native aortic valves were enrolled (pulsatile flow LVAD [TOYOBO]: 76%, continuous flow LVAD [EVAHEART, DuraHeart, Jarvik2000, HeartMate II]: 24%). Frequency of aortic valve opening and grade of AI were evaluated by the most recent echocardiography during LVAD support. None of the patients had more than trace AI preoperatively. During LVAD support AI >- grade 2 developed in 9 patients (24%) across all 5 types of devices. More severe grade of AI correlated with higher plasma B-type natriuretic peptide concentration (r=0.53, P<0.01) and with less frequent of the aortic valve (r=0.45, P<0.01). Multivariate analysis revealed that lower preoperative left ventricular ejection fraction and a continuous flow device type were independent risk factors for higher incidence of AI. Conclusions: AI, which is hemodynamically significant, develops after implantation of various types of LVADs. Physicians need to be more alert to the development of AI particularly with continuous flow devices. (Circ J 2011; 75: 1147-1155)

A newly-developed vasopressin type 2 receptor antagonist, tolvaptan (TLV), has a unique feature of diuresis, but the response to this drug can be unpredictable. Data were collected from hospitalized patients with decompensated congestive heart failure who were administered TLV at 3.75-15 mg/day (n=61). A responder/non-responder to TLV was determined as having any increase/decrease in urine volume (UV) during the next 24h after TLV treatment on the first day. Logistic regression analyses for increases in UV were performed, and independent predictors of the responder were the following: C1, baseline urine osmolality (U-OSM) >352 mOsm/L; and C2, %decrease in U-OSM >26% at 4-6h after TLV administration. Criteria consisting of C1 and C2 had a good predictability for responders by receiver-operating characteristic analysis (area under the curve=0.960). Kidneys of the non-responders no longer had diluting ability (%decrease of U-OSM at 4-6h=2.7 ± 14.6%*), but also barely kept concentrating ability (baseline U-OSM=296.4 ± 68.7*mOsm/L) with markedly reduced estimated glomerular filtration ratio (35.5 ± 29.4 m l · min(-1) · 1.73 m(-2)*) (*P352 mOsm/L for the first 4-6h predicts responders to TLV. Unresponsiveness to TLV is attributable to nephrogenic diabetes insipidus complicated by chronic renal disease.

Background: Little is known about health-related quality of life (QOL) in Japanese patients with heart failure. The purpose of this study was to identify factors related to QOL using a disease-specific QOL instrument, and to clarify whether QOL independently predicts clinical outcomes among Japanese patients with heart failure. Methods and Results: A total of 114 outpatients with heart failure were enrolled (mean age 64.7±15.8 years; 73.7% males). The Minnesota Living with Heart Failure Questionnaire (MLHFQ) to assess patient's QOL was used. At baseline, depressive symptoms and chronic kidney disease were significantly associated with worse QOL in multiple regression analysis. During a 2-year follow up, patients with a MLHFQ score ≥26, indicating worse QOL, had a higher incidence of the combined endpoint of cardiac death or hospitalization for heart failure, and a higher all-cause mortality than those with a score <26 (25.3% vs. 7.5%, P=0.011; 18.5% vs. 6.4%, P=0.018; respectively). Multivariate Cox proportional hazard models demonstrated that a higher MLHFQ score was significantly associated with increased risks of cardiac events (hazard ratio, 1.02, 95% confidential interval, 1.001-1.05, P=0.038) and of all-cause death (hazard ratio, 1.04, 95% confidential interval, 1.02-1.07, P=0.001). Conclusions: Depressive symptoms and chronic kidney disease are major determinants of impaired QOL, and the MLHFQ score is an independent predictor of both cardiac events and death among Japanese patients with heart failure. (Circ J 2011; 75: 1661-1669)