• Wall share stress Circulation 2014 129 673
• 分子メカニズム

AS進行のメカニズム

Risk factor for atherosclerosis was also risk factors for AS（JACC 2017 69 1523）

PET study ---- inflamationがASの進行に関連（Circulation 2012 125 76）

ASではLipoprotein associated phospholipase A2（LPA）がover expression

generic association with valvular calcification and AS (NEJM)

elevatied lipoprotein and AS (from JACC)

assocation of LPA

state of art paper about NHLBI working group for LPA and AS (JACC 2018 71 177-192)

ASのreview paper （NEJM 2014 371 744）must read for fellows!!

circ CQO 2009 2 533 現在のsymptomatic ASの自然歴

asymptomatic severe ASの自然歴 circ 1997 95 2262, NEJM 2000 343 611-617, circ 2010 121 151-156

management challenges

• Asymptimatic severe AS
• Low-flow, low-dradient AS
• Indication of TAVR

Asymptimatic severe AS

ACC/AHA

• Vmax >5m class2a 
• Rapid progression and low surgical risk class2b

ESC class 2a

• Vmax >5,5
• severe AS calc
• elevated BNP (JACC 2014 83 2016-2025)
• PH

Exercise test results

• symptom: class1
• hypotension: class 2a

How are "symptoms" detemined?

• Everyone has symptoms on stress test
• Are the symptoms cardiac in origin?
• What level of exercise?

How is hypotension defined?

• less than 20 mmHg increase?

ではsymptomaticになるまで待つか？

難しいのが突然死が96名中1名

ただしAVR後30日以内に死亡も6名

Ann Throrac Surg 2006 82 116

JACC 2015 6 2827（Taniguchi et al）

AVR vs. conservative approach PS match → AVR

Low-flow, low-dradient AS

Heart 2010 96 1463-1468

1/3はmean gradient <40 and AVA <1.0

treat hypertension

cadiac cath

valve calc

advanced imaging

clinical skill set

→ this scenario can be under-diagnosed and over-diagnosed

Only if clinical anatomic and hemodynamic data support severe AS: class2a

TAVR indication

heart team class 1

TAVR for prohbittive surgical risk class 1

TAVR or SAVR for high risk class 1

TAVR or SAVR for intermediate risk class 2a

SAVR for low risk class 1

TAVR for LV dysfunction --- waiting

TAVR for asymptomatic AS --- waiting

Class 1 = should be performed, not must be done

Wolbers M, Koller MT, Stel VS, et al. Competing risks analyses: objectives and approaches. Eur Heart J. 2014 Nov 7;35(42):2936-41.

Li T, Vedula SS, Hadar N, et al. Innovations in data collection, management, and archiving for systematic reviews.Ann Intern Med. 2015 Feb 17;162(4):287-94.

Pedroza C, Thanh Truong VT. Performance of models for estimating absolute risk difference in multicenter trials with binary outcome. BMC Med Res Methodol. 2016;16(1):113.

Cheung YB. A modified least-squares regression approach to the estimation of risk difference. Am J Epidemiol. 2007;166(11):1337-44.

今年になってすでに３本。

だいたい平均2週間に1本くらいのペース。

上司×2がassociate editorとして送ってくるため、なかなか手を抜くことはできない。

1つはacceptで、もう1つはmajor revision。

今回のacceptは自分の中での壁を1つ乗り越えた感じだな。

2018年は最高のスタートになった。

今年も頑張ろう。

それにしても、アメリカ人は働かないっていうのは嘘だと思う。

多分、上に行く人は、物凄く働いていると思うし、少なくとも自分の周りのcardiologyに関わっている人はworkaholicが多いように思う。やはり成功したければ、人一倍の努力が必要なんだろう。