Percutaneous coronary revascularization (PCI) in patients with stable coronary artery disease (CAD) has been more commonly performed in Japan than in outside Japan. In the past clinical practice in Japan, it was not uncommon to perform PCI even without documented myocardial ischemia. However, we now have a consensus in that PCI is not indicated in suspected stable CAD patients in whom myocardial ischemia could not be documented. On the other hands, it is still controversial whether PCI is indicated in most patients with documented myocardial ischemia. There is an on-going clinical trial, ISCHEMIA trial, which compares the invasive coronary angiography strategy with the intention of coronary revascularization versus the conservative strategy of optimal medical therapy alone without coronary angiography in stable CAD patients with documented moderate/severe myocardial ischemia. The primary results from the ISCHEMIA trial would be available at time of JCS 2020, which would be a good opportunity to discuss the ISCHEMIA trial results. In this plenary session, we will have a debate style discussion on the ISCHEMIA and other recent clinical trial results regarding the role of coronary revascularization in patients with stable CAD. ISCHEMIA is a clinical trial involving coronary revascularization in which technical issues would play important roles; We should discuss on the recent improvement of PCI outcomes including improved success rate of PCI in patients with chronic total occlusion. We would discuss how to incorporate the messages from the ISCHEMIA and other clinical trial results in the daily clinical practice. This plenary session will provide a good opportunity to have some consensus on the role of coronary revascularization in patients with stable CAD.

The prevalence of stent thrombosis has been decreasing, thanks to current improvements of drug-eluting stents. In contrast, antithrombotic regimen following percutaneous coronary intervention (PCI) remains conservative. Because excessive administration of antithrombotic agents may potentially cause bleeding events, the patients with the greatest concerns of such complications have been selected, and then targeted as subjects for the clinical studies to evaluated safety and efficacy of de-escalation regimens of antithrombotic drugs. For example, several randomized control trials for patients with atrial fibrillation have suggested anticoagulant therapy with thienopyridine, skipping aspirin. Guidelines start to recommend anticoagulant monotherapy after one year for such population. Furthermore, even for the patients without atrial fibrillation, the patients with high bleeding risks (HBR) were selected and entered into randomized clinical studies to evaluate shorter duration of dual antiplatelet therapy (DAPT) compared with conservative arms or bare metal stents. As a result, current guidelines mention shortening the duration of DAPT for the HBR patients.
One of strength points of Japanese PCI has been considered as very low stent thrombosis rates.
Frequent usage of intravascular imaging modalities or racial characteristics have been recognized to contribute these outcomes. Considering our nature to complicate with more bleeding events, recently, Japanese several clinical groups have aggressively planed de-escalation programs of clinical studies, including OAC alone, AFIRE, STOPDAPT, STOPDAPT 2, MODEL-U, and OPTIMA-AF, whose results are gradually elucidating. They appear to demand early modification of current Japanese guideline. In this session we are going to share the latest status in these issues and discuss multidirectionally about “how far can we advance de-escalation”, which must be very “cutting edge” for the audience.

We are entering the aged society as no country had never experienced, in Japan. In this aged society, the cost in medical care or nursing elderly will increase and the great financial burden for the government will be problems in near future. Healthy life expansion is necessary to overcome these problems. One of the worse causes of disturbing healthy life expansion is stoke. There three kinds of stroke are cerebral hemorrhage, sub arachnoid hemorrhage and ischemic stork. Ischemic stroke is a leading cause of stroke among them and is increasing as the aged society. Seventy five percent of causes of ischemic stroke has been revealed such as lacuna, atheroembolic, cardiogenic and others (aneurysm, dissection, aortitis and so on). In another words, the cause of 25% of ischemic stroke has been unknown, so this type of ischemic stroke is called as ESUS (Embolic Source of Undetermined Source). DOAC has been tested to prevent the recurrence of ESUS, but no DOCA could not show the efficacy compared to anti-platelet agents. This result indicated that the embolic source was not heart and must be found out as soon as possible to overcome the stroke. We expected to open the new window to resolve this issue with the great collaboration between cardiologists and neurologists in this plenary session.

The treatment strategies for acute/chronic aortic dissection (AD) remain controversial. Particularly, in cases with acute AD requiring the emergency cares, a series of the treatment flow consisting of quick and accurate diagnosis and appropriate management without delay should be mandatory for patients’ life-saving. In most, in the emergency settings, the diagnoses of acute AD are made by emergency staffs or CCU staffs using echocardiography and CT/MRI examination. According to the settings such as anatomical type, conditions of the false lumen, and presence/severity of AD complications, optimal treatments such as medical treatments (MT), open repairs (OR), and endovascular treatments (EVT), are decided and performed, predominantly by cardiac/vascular surgeons and interventional cardiologists/radiologists. However, the recent surgical treatment tactics have been shifted towards the less-invasive EVT, which are fitted to interventional radiologists/cardiologists and vascular surgeons. Subsequently, the opportunities of treatments by these non-surgical interventionalists have been increasing. Particularly, in the hybrid operation rooms where both OR and EVT are feasible, meticulous non-delayed emergency cares from the diagnosis to the treatment by a multidisciplinary AORTA TEAM have been reported. In this session, for further improvement of AD cares, recent important issues "Who will diagnose? Who will treat?" including the surveillance strategy for chronic AD would be discussed, based on the treatment strategies by a multidisciplinary AORTA TEAM.

The number of patients with chronic limb-threatening ischaemia (CLTI) among arteriosclerosis obliterans tends to increase because of aging, prevalence of diabetes mellitus and increased chronic kidney disease stage. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial was reported in 2005. After that, together with evolution of endovascular therapy (EVT), surgery has been considered if patients with CLTI have a life expectancy of more than two years and have an usable saphenous vein.
On the other hand, EVT has been considered as the first-choice treatment of CLTI patients with a life expectancy of less than two years. However, in current real-world practice, treatment choice for CLTI has not been strictly based on this recommendation.
In the 2017 European Society for Vascular Surgery (ESVS) / ESC Guidelines, the Society for Vascular Surgery (SVS) Wound, Ischemia, and foot Infection (WIfI) classification was added and autologous vein bypass was described for patients with CLTI class I recommendation. A new Global Vascular Guideline will be published, in which it is recommended that treatment of CLTI is systemically selected based on the severity of systemic disease, wound severity and anatomical severity. In Japan, unlike other countries, patients with chronic renal failure, especially maintenance dialysis commonly have concurrent CLTI, for which vascular surgeons and physicians commonly have difficulties in selecting a treatment strategy in the real-world practice. Considering these backgrounds, we would like to discuss on the CLTI strategy with the enthusiastic vascular surgeons and physicians involved in management of CLTI, and to give a presentation on current multidisciplinary therapy for CLTI along with the modified guidelines.

Heart failure is a clinical syndrome that results from the breakdown of cardiac pump function by the occurrence of organic and/or functional abnormalities in the heart. The recent increase in heart failure patients has become a major medical and social problem. Heart failure is roughly classified into heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). In addition, a condition called heart failure with mid-range ejection fraction (HFmrEF) is also attracting attention.
Elucidation of the molecular mechanisms involved in the pathogenesis of heart failure has progressed particularly in HFrEF. On the other hand, the prognosis of HFrEF reaching Stage D is still poor at present, the prognosis of HFpEF is not good at all, and even its treatment has not been established yet. The improving the prognosis may require new findings on molecular mechanisms that are involved in the onset or exacerbation of heart failure. In this session, we would like to discuss the future prospects of heart failure medicine from the latest research findings on the molecular mechanism of heart failure.

Among most of the patients suffering chronic advanced heart failure, guideline-directed medical therapy including pharmacological or non-pharmacological treatment is unsuccessful to control their symptoms. They are assigned as stage D heart failure, and the strategy is very limited. These stage D patients have been known to have poor long-term prognosis. Cardiac replacement therapy such as implantable left ventricular assist device or heart transplantation is only established strategy for the improvement of their long-term outcomes, but not everybody has the indication for such kind of therapy. As a result, many of stage D heart failure patients are candidates for palliative care. In any case of stage D heart failure, multidisciplinary team approach is indispensable, and a variety of knowledge must be necessary to manage complex situations. On the other hand, the acute setting of cardiogenic shock is another challenge for cardiologists, and it also needs multidisciplinary approach for timely action to handle deteriorating hemodynamics. The topic of this session will be state-of-the art treatment of advanced heart failure, in both acute and chronic phase. Especially, we would like to discuss about new devices introducing recently. We also like to focus on unmet needs and future perspectives of advanced heart failure.

There is no specific treatment for cardiac amyloidosis, and it has been recognized as a group of intractable diseases with progressive cardiac dysfunction and heart failure. In addition, the diagnosis is based on the proof of the presence of amyloid in the tissue biopsy, and the diagnosis is difficult for the general physician. On the other hand, as the number of elderly patients with heart failure has increased in recent years, it has been found that cardiac amyloidosis is more prevalent than expected as the underlying heart disease, and the coexistence of cardiac amyloidosis in patients undergoing TAVI has become a problem in some cases. With regard to treatment, the results of the ATTR-ACT trial have been reported, and it has been reported that tafamidis meglumine, which has been used to suppress the progression of peripheral neuropathy in hereditary transthyretin (variant) amyloidosis of rare diseases, is also effective for cardiomyopathy caused by wild-type and mutant transthyretin, and its indication has been expanded in Japan. In this context, accurate diagnosis of cardiac amyloidosis and timely treatment interventions are becoming more and more important. At the same time, there are a number of issues such as how to perform highly accurate screening for cardiac amyloidosis, how to make an efficient definitive diagnosis, how to utilize sophisticated imaging findings for diagnosis, and how to select patients for new treatment interventions. In this session, we would like to discuss the prospects and direction of future diagnosis and treatment with an expert in cardiac amyloidosis who will explain the latest data.

Minimally invasive cardiac surgery (MICS) has been performed for valvular diseases, simple congenital cardiac anomaly as atrial septal defect, cardiac tumor, and coronary bypass.
Of them, valve repair/replacement under endoscopic assist got special evaluation in Japanese health insurance in 2018. Robotic valve repair was also admitted by the insurance system. Currently we have three different methods for MICS: endoscopic assist, total endoscopic, and robotic. Of three representative methods, we ask speakers discuss safety, operation time, benefit for patients and surgeons, and future perspective of each method, based on their solid data.
Significance of MICS for other diseases, currently not defined as MICS under health insurance system, as congenital heart diseases, cardiac tumor, coronary bypass, and aortic disease, is also encouraged to be discussed based on evidence.

The number of aortic surgical cases is dramatically increasing, especially with the advent of an aging society. The outcome of these surgical procedures is generally improving due to new devices such as stent-graft and novel strategies such as cerebral and spinal protection.
Recent research has also led to a much better understanding of non-atherosclerotic aortic diseases, such as familial aortic disease including Marfan syndrome and aortopathy with congenital bicuspid aortic valve. Populations suffering from these diseases have a higher risk of developing acute aortic dissection. Valve-sparing root replacement is emerging as the standard strategy instead of Bentall procedure for aortic root disease in these populations. The root procedures are thought to prevent the aortic dissection. Furthermore, familial aortic disease is characterized by aortic dilatation. Consequently, the surgical interventions for non-atherosclerotic aortic diseases are aggressively performed compared with those for the atherosclerotic aortic diseases.
Patients with non-atherosclerotic aortic diseases are generally young and actively working. Moreover, they tend to have extended lesions with aortic dissection. Therefore, surgical strategies must consider their longer and more active life. More invasive and one-stage or extended treatment could be selected in this younger population, although less invasive and staged treatment might offer better patient safety despite frequent admission to the hospitals. A case-by-case approach will be necessary to make a better judgment on the choice of surgical approach.
Lively discussion regarding the surgical strategy based on recent research and long-term follow-up data can be expected in this session.

New Japanese Guidelines for the Management of Hypertension (JSH2019) has been published in April, 2019. JSH2019, as well as the current American (2017ACC/AHA) and European (2018ESC/ESH) guidelines, recommended more strict blood pressure control in hypertensive patients, irrespectively of their cardiovascular risk levels or comorbidities. It is interesting to note that all the guidelines share the risk awareness of “hypertension paradox”, the status where the adequate control of hypertension has not been achieved despite the remarkable advances in the diagnosis and treatment of hypertension. Thus, a lot has been mentioned regarding the attempts for improving hypertension management, including the establishment of the personalized medicine using the out-of-office BP measurements, team medicine in cooperation with medical and non-medical staffs, and the changes in doctors’ attitude overcoming “clinical inertia”. Recently, the Stroke/Cardiovascular Control Act has been passed. Taken together, new era has come for hypertension prevention and management. In this session, we welcome the presentations and discussion on the remaining issues and the future way of blood pressure control for primary and secondary prevention of coronary artery disease, heart failure, atrial fibrillation, and strokes. Also, we would like to discuss how to take advantage of JSH2019 to improve clinical practice of cardiovascular medicine.

The number of adult congenital heart disease (ACHD) patients is increasing year by year, and there are already more than 500,000 ACHD patients. In order for these patients to live better lives in society, it is necessary to establish a lifelong medical care system including transitional care from children to adults.
Children need a system of “self-independent education” that enables them to understand their own diseases and self-management, and it is necessary to understand the treatment and response to disease processes and complications that may change with growth and development.
In adults, not only medical treatment related to congenital heart disease but also specialized medical treatment including lifestyle-related diseases are necessary, and construction of medical facilities and medical treatment networks for performing these specialized medical treatments is essential. In addition, social welfare system design to develop ACHD specialized medical treatment in society such as schooling, working becomes indispensable.
In order to facilitate the transition from a child to an adult, the combined efforts of establishing the basic system of medicine-social welfare-education is mandatory from both the medical side and the patient's side receiving medical care.
In terms of social systems, from the Japanese Circulation society and the 8 alliance academic societies, a "Recommendation on transition medical treatment for congenital heart disease to adults" was issued in 2017 and 2019. Along with the establishment of "Strategy against stroke and circulatory disease" and “the Basic Law child and maternal health and child development” , the more specific policy of provided medicine is needed to be discussed. In this plenary session, based on these backgrounds, we would like to discuss the future directions for the medical system necessary for adult congenital heart disease management.

Over the past two decades, researchers have struggled to account for the heritability of heart disease, diabetes and schizophrenia. Genome-wide association studies (GWASs) became very popular in this research field. But after searching many years, scientists could still only explain a small bit of the inherited risk for common diseases. While, polygenic scores add together the small contributions of tens to millions of spots on the genome, to create some of the most powerful genetic diagnostics to date. Some studies published in the past several years have been able to analyses more than a million participants by combining information from a number of well-resourced cohort studies and large data repositories, which increased scientists' ability to detect tiny effects. Polygenic scores are racing to the clinic and are already being offered to consumers by some companies.
However, there are several problems in risk prediction. They include 1) the missing heritability, 2) limited application of risk score to certain ethnicities, and 3) concerns of how to communicate these scores to people.
This plenary session will deal with the latest results of genomic analysis of patients with coronary artery and associated diseases and we would like to discuss the problems listed above.

Regenerative medicine had been investigated in many fields using various type of stem cells, and some of them were applied for clinical use. In the cardiovascular field, clinical application of regenerative medicine had been also investigated using cardiac stem cells, skeletal myoblasts, mesenchymal stem cells, ES cells, and iPS cells.　There is a wide variation of therapeutic cell sources and methods of transplantation. Some of these treatments includes direct transplantation of regenerated cardiomyocytes, and others expected that humoral factors (growth factors and cytokines) secreted from the transplanted cells improve cardiac function. Methods for transplantation also have varieties such as intra-coronary administration, direct injection into the ventricular wall, and application of cell sheets on the surface of the epicardium. In this plenary session, we focused on the studies which locate very close to the clinical trials. We would like to ask the speakers to clarify how much the basic research approach to the clinic, how much the preclinical studies (safety test, tumorgenesity test) have been finished, what kind of heart disease is the target, how many cells will be transplanted, how to transplant the cells, how much and how long the transplanted cells will survive, and how to prevent the tumor formation, how much we can expect the improvement of ejection fraction, and what is the mechanism of improvement of cardiac function. We would like to discuss the future direction of regenerative medicine to achieve our final goal.

Intracellular signaling pathways in cardiac hypertrophy and failure have been well elucidated, but therapeutic approaches targeting these pathways have not been established yet. Specific intracellular signaling pathways finally result in specific gene expressions, which are regulated by epigenome. Some non-coding RNAs which are regulated by these specific signaling pathways regulate specific gene expressions. Recent technical advances in epigenomic and single-cell analysis have driven our understanding in epigenetic and transcriptional machinery associated with intracellular signaling pathways in the heart. In this session, frontier researchers will not only introduce the advanced cardiovascular science which dissects the underlying relationship between epigenome/RNAs and intracellular signaling pathways by utilizing cutting-edge technologies, but also discuss future perspectives for the development of therapeutic approaches in cardiac hypertrophy and failure via epigenetic and transcriptional mechanisms.

Myocardial infarction and cerebral infarction develop due to arterial thrombi based on atherosclerosis. Atrial fibrillation is associated with thromboembolism. Deep vein thrombosis and pulmonary embolism occur based on venous thrombosis. Thus, thrombosis causes many important cardiovascular diseases. In the basic research field, the role of neutrophils has recently noted. The role of the intrinsic coagulation system consisting of several factors such as factor XI has also been clarified. Genetical analysis has proceeded in Japanese population to reveal prothrombotic SNP and mutations as risks of thrombotic diseases.
The cancer- and cancer therapy-associated thrombosis is also noted. The mechanism of the thrombosis is expected to be elucidated while involvement of tissue factors and mucins has been considered as causes of it.
It is also recognized that control of thrombosis and bleeding is very important on the treatment with mechanical circulatory support such as VA-ECMO and implantable left ventricular assist device (LVAD) for patients with severe heart/circulatory failure. In the field, especially, high shear stress-induced acquired von Willebrand syndrome is noted and its control method is urgently expected to be developed.
Thus, in this symposium, recent advancement of the research field of thrombosis with close relationship to the circulatory medicine will be discussed. If possible, we would emphasize researches on the ‘mechanism’. We hope that many papers are applied for the symposium.

Understanding the mechanism of arterial wall remodeling, a fundamental mechanism of cardiovascular diseases (CVD), is essential for developing effective clinical strategies for CVD. For example, understanding of the biology of intimal hyperplasia contributed to the prevention of the restenosis of coronary arteries after percutaneous coronary intervention as a form of drug eluting stent. The knowledge of the multifaceted mechanism of atherosclerosis resulted in the combinatorial approach to control the lipid and glucose metabolism, obesity and hypertension to prevent CVD. However, even with the combinatorial approach, CVD remains a significant health burden in Japan due to the residual risk for CVD. In addition, although aortic aneurysm and dissection are also caused by arterial wall remodeling, their mechanisms seem to be different from that in atherosclerosis, and the mortality of acute aortic syndrome remains high due to their unsolved mechanisms. Because understanding the complex mechanism of arterial wall remodeling requires a variety of research approaches in basic and clinical sciences, these vascular diseases are correctively listed as one of three major challenges in the five year plan to conquer cerebro- and cardiovascular diseases in Japan. In this symposium, we called for recent findings in the research for mechanism of arterial wall remodeling in vascular diseases. We envision that comprehending such findings will facilitate the understanding of arterial wall remodeling, which is essential for tackling CVD to prolong our healthy life span.

Atrial Fibrillation (AF) is one of the most frequently observed arrhythmias in the clinical practice. More than a million AF patients are estimated to be present in Japan, most of whom are examined for the first time by general physicians (GPs) rather than arrhythmologists. AF coexists hypertension, diabetes mellitus or chronic kidney disease (CKD), and is associated with cardiogenic cerebral infarction, heart failure (HF) and dementia etc. Catheter ablation (CA; pulmonary vein isolation) has spread since early 2000 as a cure, and is currently conducted in almost 70 thousand AF patients per year along with the establishment of the procedure, efficacy and safety. 2018 JCS/JHRS Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias has recommended CA as a first line therapy for symptomatic AF patients even without medication. Moreover, recent randomized control trials have reported CA for AF patients with HF was associated with a significantly lower rate of death or hospitalization for worsening HF than was medical therapy (CASTLE-AF). CABANA trial has reported CA led to significant improvements in quality of life at 12 months among compared with medical therapy among symptomatic AF patients. On the other hand, some divergence on the indication of CA for AF are recognized between arrhythmologists, cardiologists (non-arrhythmologists) and GPs. In this symposium, arrhythmologists, cardiologists and GPs are welcome to present their own experience and discuss on the indication and future of CA for AF.

Atrial fibrillation is the most frequent arrhythmia prophesized by Professor Braunwald in 1997 as “21st century’s cardiac pandemic.” There are 940,000 atrial fibrillation patients registered by Ministry of Health, Labor and Welfare in 2018 and the number is predicted to be over 1,000,000 in 2022. In addition, the number of undiagnosed atrial fibrillation (latent atrial fibrillation) is deduced to be the similar to that of diagnosed atrial fibrillation. High commodity of stroke (cardiogenic embolism) is the medical and social serious problem. Among 3 types of stroke, cardiogenic embolism becomes most severe. Thus, since 2011 novel anticoagulants (DOACs) have been placed on the market one after another, and the association of stroke can be successfully prevented to some extent in patients with diagnosed atrial fibrillation. As a result, association of stroke in latent atrial fibrillation has turned out to be an unmet-need. Majority of latent atrial fibrillation are paroxysmal, and about half of them are asymptomatic, so that the detection of latent atrial fibrillation is quite challenging. Thus, the application of state-of-the-art preventive medicine, precision medicine, is warranted. In this symposium, Japanese front-runners in this field will give us lectures including atrial fibrillation risk stratification based on multi-layer information including genetic information, latent atrial fibrillation detection with IoT devised, and utilization of artificial intelligence (AI).

Based on the several randomized comparison studies, an indication for the implantable cardioverter defibrillator has been established as a primary and secondary prevention for sudden cardiac death. However, these randomized comparison studies were conducted in Western countries. Given the difference in underlying heart disease and incidence of sudden cardiac death in Japanese patients, there have been extensive discussion whether the same criteria is appropriate. There is a paucity of data in sudden cardiac death in non-ischemic cardiomyopathy patients, but is similar to that of Western patients. In contrast, it has been shown that the prognosis of ischemic cardiomyopathy patients in Japan have better prognosis, suggesting the poor cost effectiveness of ICD implantation based on the MADIT-II type criteria. Other screening tests might well be required. In this symposium, we would like to discuss the effective use of ICD based on the evidence from Japan.

The number of heart-failure patients is growing over the globe. In Japan, this increase is remarkable because of the rapid shift of population towards elderly. It is urgent to focus on the heart-failure patients in elderly. In 2016, the Japan Heart Failure Society published a statement regarding this problem and proposed systematic renovation for these elder patients. In this symposium, we will discuss the problems that should be solved for our super-aging society with heart failure patients and will address innovative approaches conducted in our societies and communities.

Because the right ventricle is strongly affected by the afterload generated in pulmonary circulation, the leading cause of right-sided heart failure (RHF) is right ventricular (RV) dysfunction caused by type I and type II pulmonary hypertension. However, it is unclear whether it is possible to evaluate RV intrinsic function in the setting of increases in afterload. Also, although tricuspid regurgitation (TR) often coexisting in RHF increases RV preload, no conclusion has been reached as to the appropriate methods to evaluate RV function complicated by TR. On the other hand, in addition to hypoperfusion due to left-sided heart failure, an increase in RV filling pressure due to RHF causes organ congestion and promotes multi-organ failure. Therefore, RHF can be regarded as a systemic disease caused by congestion in the venous system, which is a more serious issue in adult congenital heart disease represented by Fontan circulation. Thus, as the importance of RHF is recognized, it has become clear that many problems remain in the elucidation and diagnosis of the pathophysiological condition. In addition, in the treatment of RHF, diuretics are used to improve congestion, but the optimal treatment method has not been established, and it remains unclear what benchmark should be used as an indicator of treatments. Meanwhile, advanced RHF requires a discussion about surgical intervention. As described above, there are various problems in the treatment method from standard diuretic treatment to invasive interventions. Therefore, in this session, we would like to clarify the current issues on the pathogenesis of RHF, diagnostic methods, and treatment methods based on the findings so far, and discuss the prospects comprehensively.

The number of patients with heart failure (HF), particularly elder patients, has continuously increased, and this phenomenon is termed as “HF pandemic”. Efficacious approach to improve symptoms, exercise tolerance and quality of life as well as prognosis of HF patients remains to be established. Worsening of HF is related not only to cardiac dysfunction but also to many non-cardiac factors. Cachexia has been recognized as one of comorbidities of severe HF. Recently, it has been revealed that other systemic issues such as sarcopenia and frailty are more frequently associated with HF and are related to symptoms and prognosis. These issues are likely to result from malnutrition, and malnutrition is noticed as a new therapeutic target of HF.
To approach malnutrition of HF patients, followings are awaited; the establishment of the evaluation method of nutritional status, the elucidation of causes for malnutrition and of interaction between malnutrition and pathophysiology of HF, discovery of efficacious intervention to malnutrition. The beneficial effects of some interventions have been reported abroad. However, the intervention is strongly affected by dietary habits and evidences of other countries cannot be easily introduced to Japan.
In this symposium, current information in Japan will be presented and active discussion will be expected.

FFR-CT utilizes computational fluid dynamics (CFD) to determine fractional flow reserve (FFR) from three-dimensional CT images of the coronary artery, and allows for the detection of flow-limiting stenosis in the coronary artery without use of intracoronary-pressure measurement or stress myocardial perfusion imaging. A sub-study of the ADVANCE registry that analyzed Japanese population demonstrated that reclassification of treatment strategy between CTA alone and CTA + FFR-CT occurred in >50% of the patients, resulting in the reduction of execution rate of invasive coronary angiography and PCI. FFR-CT was covered by the national healthy insurance on Dec 1st, 2018 in the hospitals with accreditations of training by both JRS/CVIT and JRS. In this symposium, we will discuss about the current usage of CT-FFR in Japan, tricks and tips to obtain high-quality coronary CTA images for the successful FFR-CT analysis, and practical issues related to safe and fast data transfer between each hospital and HeartFlow Server in USA. Then we will determine the reduction of invasive coronary angiography and PCI by FFR-CT performed as a routine clinical imaging test, investigate the event rates in patients with and without reduction of FFR demonstrated by FFR-CT. The impacts of FFR-CT in managing patients with coronary artery disease and reducing health-care cost, as well as the issues to be solved, will be discussed in this session.

We are beginning to see AI being applied to various fields in the medical field. In cardiology field, AI has been tested to evaluate coronary ischemia based on automated FFR measurements by coronary CT images and functional evaluation of myocardial ischemia based on SPECT nuclear imaging. Echocardiography based AI diagnosis may be useful to assess left ventricular systolic and diastolic function. Moreover, regional myocardial wall motion assessment may be possible to automatically diagnose ischemic territory. There still are some limitations to be addressed, such as its dependency on image quality and inter-vender differences. In this symposium, recent advancements of AI in cardiology field will be discussed.

In primary mitral regurgitation, there is a trend towards performing earlier operation (Early Surgery) as long as repair is possible and there is no operative risk, even though there are no triggers for surgery, such as heart failure symptoms, left ventricular decompensation, new onset of atrial fibrillation or pulmonary hypertension based on AHA/ACC and ESC/EACTS guidelines. However, the incidence of Early Surgery and its outcomes including long-term have not been reported. In order to improve prognosis of patients with primary mitral regurgitation, the purpose of the present symposium is to evaluate long-term outcomes related to the timing of operation based on triggers for surgery, recommendation classes, and other parameters. Also, in Early Surgery without any triggers, factors (echocardiographic parameters, biomarkers, etc.) that may affect long-term surgical outcomes could be discussed with evidences.

Cardiac rehabilitation (CR) is a comprehensive therapeutic approach, including exercise therapy, diet, patient education and psychological intervention for patients with cardiac disease. CR come to be recognized as long-term intervention to improve prognosis and quality of life of cardiac patients by multidisciplinary team approach. Therefore CR is recommended in guidelines of acute myocardial infarction and chronic heart failure. Thus, we can obtain maximum benefit from CR through a disease management program. However, in Japan the implementation rate of CR are still poor. The great majority of patients cannot take benefit from CR. It is expected that the potentiality and needs of CR become more and more important in the future.
In the epidemiologic studies about the prediction of chronic heart failure (CHF), it is estimated that the number of CHF patients will reach 1.3million in 2030. Especially CHF is highly prevalent in older individuals and is a major cause of morbidity, mortality, hospitalizations, and disability. The characteristics of elderly CHF patients reveal that they have some comorbidities and frailty. Because frailty seems to be a core factor to increase a care burden to caregiver, early action for prevention of frailty becomes important.
How can we manage CHF patients in acute phase?
How should we prevent readmission of elderly patients?
How can we work on prevention of cardiovascular disease?
The chairmen expect challenging and talent studies about these problems.

Recent progress of diagnosis and treatment improve outcome in congenital heart disease. The long term outcome and related problems had become paid attention to. These problems include arrhythmia, heart failure, and sudden cardiac death. Specifically in congenital heart disease patients, we should consider the operation indication in such situation, which means the appropriate timing and assessment for indication of operation/reoperation should be discussed. Among many congenital heart diseases, we would like to focus on Tetralogy of Fallot and post Fontan operation patients. We wait many abstract submissions about this topic. Also it is especially important team medical work in corporation by many departments, particularly in this area.
For example, in TOF patients, tricuspid valve repairment/ICD/reoperation timing might be suited to this session. In post Fontan operation patients, management of long-term complications such as protein losing enteropathy could be the example. More generalizable data analysis might be preferred.

Pulmonary endarterectomy (PEA), balloon pulmonary angioplasty(BPA), and PAH specific medicine have been established as standard care for chronic thromboembolic pulmonary hypertension (CTEPH). Outcomes of each treatment have been revealed and issues to be addressed come to light.
PEA is mainly indicated to patients with proximal disease. It has shown that relatively high hospital mortality and residual pulmonary hypertension had adverse impacts on short and long-term survival after PEA. Residual pulmonary hypertension could be effectively treated with BPA and PAH specific medicine, and thus their survival is expected to be improved. Bridging therapy for PEA with PAH specific medicine and combined therapy with BPA have been developed for possible reduction of hospital mortality of high risk patients.
BPA is indicated to inoperable patients. Japanese multicenter registry data showed that BPA offered substantial and sustained improvement of pulmonary hypertension and favorable long-term survival, whereas a minority of patients suffered from insufficient improvement of symptoms and cardiac output. Combined therapy with PAH specific medicine may help resolving these issues.
In Japan, great efforts to improve short and long-term survival and provide more effective and safer treatment have been made. Combined therapy with PEA, BPA, and PAH specific medicine has already been introduced. In this session, we would like to discuss updated treatment strategy and explore a future direction of appropriate CTEPH treatment.

Recent advanced clinical practice concerning congenital heart disease (CHD), including complex cardiac anomaly, has enabled most women with CHD to reach childbearing age. Diagnoses of inherited cardiovascular diseases (CVD), connective tissue diseases and channelopathies can be made while patients are young. Based on this background, involving advanced maternal age, the number of pregnancy complicated with CVD has increased. Because maternal hemodynamics dramatically changes during pregnancy and delivery, maternal mortality and morbidity risks become high in some diseases and conditions. Even for these high-risk pregnant women needing immediate treatments, we need special caution in using invasive procedures and medications, considering the adverse effects on their fetus. So, when high-risk women get pregnant, careful follow-up through antepartum to postpartum by a multidisciplinary team is needed.
The symposium presents and discusses about clinical practice including preconception, antepartum, intrapartum and postpartum managements of women with CVD, especially focused on high-risk cases.

Systemic metabolic abnormalities, such as those defined as metabolic syndrome, are associated with the development of multiple disorders in the cardiovascular system. Abnormalities in glucose and lipid metabolism are well established risk factors for atherosclerotic cardiovascular diseases, heart failure and atrial fibrillation. On the other hand, cardiovascular dysfunction can affect function of organs that play important roles in regulating systemic metabolism. Unraveling the cross-talk between cardiovascular system and organs controlling systemic metabolism will lead to better understanding of roles of metabolic disorders in pathophysiology of cardiovascular diseases and molecular mechanisms underlying the pathological process. In this symposium, novel topics regarding the cross-talk between cardiovascular diseases and metabolic disorders and its underlying mechanisms will be discussed.

Basic law regarding stroke, heart disease and other cardiovascular diseases to extend healthy life span has been promulgated and the medical care system for prevention, diagnosis, and treatment of cardiovascular diseases at national level has been strengthened as well as cancer. However, the planning and implementation of the nationwide project is probably still time-consuming and we cannot wait for the time to put it into clinical practice. In particular, the responses to cardiovascular emergency including prehospital cooperation and communication must be done promptly and appropriately. Because all cardiovascular emergency diseases require a rapid response with the concept of “time is muscle”. However, it is difficult to say that the current situation of the emergency medical cooperation system is not satisfied. Even in acute myocardial infarction, acquisition and transmission to the hospital of pre-hospital 12-lead-electrocardiograms has not been sufficiently performed in Japan, although it has been available in western countries based on the guidelines. Furthermore, pre-hospital initiation of continuous positive airway pressure for acute cardiogenic pulmonary edema has not been practiced despite being conducted in some regions of western countries. Based on these backgrounds, we should recognize the practical problems in the cardiovascular emergency system not only for the medical care system for resuscitation but also for all cardiovascular disease-response system including prehospital cooperation and communication and try to find some solutions for them out. In this session, we would like to discuss about medical cooperation and communication of cardiovascular emergency diseases such as acute coronary syndrome, acute heart failure, acute aortic syndrome, acute pulmonary thromboembolism, and so on with intensivists and emergency care physicians and staffs.

Cardio-oncology / Onco-cardiology has emerged as one of the most quickly expanding fields of cardiovascular medicine, in the research, the education, and the clinical practice. Traditional, molecularly targeted, and immune-based cancer therapies have contributed to the impressive revolution in oncology. However, there are more questions than answers when exponentially increasing number of dedicated onco-cardiology services throughout the world recognize novel clinical presentations and disease entities. In this symposium, inter-disciplinary challenges and opportunities, to accumulate evidence for risk stratification and early diagnosis of wide variety of cardiovascular pathophysiology including heart failure, atherosclerosis, arrhythmia, hypertension, thromboembolism, etc., will be discussed.

In 2013, the committee in ministry of health, labor and welfare (MHLW) for the problems of Japanese medical specialty system concluded that new system for the medical specialty board is recommended to be developed, which should be controlled by the policy of professional autonomy with independency, have a 2 step system of fundamental and subspecialty area, and have general medicine specialty as a fundamental board. Immediately after the announcement of the above conclusion, the Japanese medical specialty board organization was established and the detailed fundamental system was constructed by 4 years effort of many volunteers from medical and surgical societies. However, Japan medical association announced to worry about the deterioration of regional medicine by the new system in February 2017 which was 2 months before the estimated starting date of the new system. Thereafter, the new system seemed to be confused and further discussion for the basic structure of the system began, such as what is subspecialty?
Therefore, we ask MHLW and the president of Japanese medical specialty board to explain the present complex issues in order to understand the problems of the new medical specialty system. Then, we will discuss about optimal system for subspecialty with the opinion of regional medicine of cardiology.

Telemedicine, which connects medical personnel and patients online, includes three elements: telemonitoring, tele interviews, and telediagnoses. With the development of the Internet and advances in sensor technology, various medical devices have become wirelessly connected to networks and telemedicine has made great strides. As an example, remote monitoring of cardiac implantable devices became covered by insurance in 2010 and today tens of thousands of patients use this system. Remote monitoring captures signs of device failure, arrhythmias, and worsening heart failure prior to the scheduled face-to-face consultation. If high-speed and large-capacity information communication is possible with the 5th generation mobile communication system (5G), conversations without a time lag can be made while watching high-definition still images and moving pictures, so a continuous and more accurate interview can become true. Furthermore, in addition to 3D images that capture the patient's face and movements, real-time reception of modalities such as electronic stethoscopes and echo images and tactile communication may result in more accurate medical care. Previous studies have proven that telemedicine may improve the quality of the medical services and reduce medical expenses, but on the other hand, there are still many legal and insurance regulations regarding telemedicine, manpower issues, and operation cost challenges left. In this session, we will talk about the activities using IoT technology in the field of cardiovascular medicine and discuss the current issues and future direction.

In order to develop the medical care in cardiovascular field, it is both important to promote the development of innovative drugs and medical devices, and conduct clinical research to optimize medicine, such as comparison of approved drugs and improvement of guidelines. These studies have been carried out under the Good Clinical Practice or the Ethical Guidelines for Medical and Health Research Involving Human Subjects. Since April 2018 when the Clinical Trial Act (“the ACT”) was enforced, the number of the studies applied with the Act is increasing. In this symposium, we would like to discuss the following issues; 1) How things should be in the post-marketing large clinical study supported by the pharmaceutical companies, 2) How are the effects of the ACT on the development of medical equipment including the engineering side which is very important in cardiovascular medicine, 3) How are the effects of the ACT in epidemiological studies even though the Act does not directly apply, 4) What kinds of the support by Academic Research Organization (ARO) or Clinical Research Core Hospital is available in the management of the researches which is required by the ACT to keep the quality of the study. We expect the comments by researchers, research-supporting institutes, industries, and administration sides. The presenter about the post-marketing large clinical study supported by the pharmaceutical companies will be selected through the application.

In Japan, we have previously suffered from numerous natural disasters. Furthermore, it is currently predicted that we will soon have the Tokyo near-field earthquake and the Nankai Trough large-scale earthquake. The incidence of cardiovascular disease is known to be rapidly increased in response to various stresses. Indeed, during the Great East Japan Earthquake, we experienced the rapid increases in cardiovascular diseases, including heart failure, acute coronary syndrome, sudden cardiac death, pulmonary thromboembolism, and hypertension. Thus, we always need to prepare for such natural disasters as health care professionals in Japan.
As for the disaster cardiovascular medicine, we need to improve both the system construction and institutional preparation at each hospital.
Regarding the system construction, the Japanese Circulation Society (Disaster Measures Committee) has established the disasters countermeasures headquarters system in collaboration with the 9 JCS branches for local natural disasters. This system worked well during the recent local earthquakes in Osaka and Hokkaido. The Disaster Measures Committee is now preparing for the Tokyo near-field earthquake and the Nankai Trough large-scale earthquake. At this moment, the JCS has made the policy to collaborate with the disasters headquarters in each prefecture and JMAT by the Japanese Medical Association.
Regarding the institutional preparation at each hospital, it is recommended to prepare food, drinking water, drugs, portable toilets, and elastic stockings, in addition to in-hospital disaster prevention system.
In this symposium, we will first ask the Japanese Medical Association and the Japanese Ministry of Health, Labor, and Welfare, to present their current policies. Then, we, the JCS, will present our past activities for disaster cardiovascular medicine. Finally, several local hospitals will present their past institutional activities for natural disasters. We hope that this symposium will help the JCS members and others prepare for future natural disasters.

The government's work-style reform legislation came into force on April 1st, 2019 in order to place the first-ever legal cap on the hours of overtime work and realize fair treatment for all workers with backgrounds of decrease in production age population due to declining birthrate and diversification of workers' demands. The new rule in principle limits an employee's overtime to 45 hours a month and 360 hours a year. To respond to the increased workload during busy seasons, a labor-management agreement can extend the limit up to 99 hours a month, up to an average of 80 hours monthly over a period of two to six months, and up to 720 hours a year. However, medical professionals, especially doctors with excessive workloads ever criticized, are exempt from the rule for five years. The government requested an expert panel to propose how to regulate overwork of doctors and planned the overtime regulation to become effective in fiscal 2024. The panel has finally proposed in March, 2019 that the new rule should principally limit doctor's overtime to 100 hours a month and 960 hours a year, and the limit can be extended up to 1,860 hours a year to keep adequate management of community health care and continuous upgrade of health care skills. Additionally, the panel proposed to regulate to take adequate break-time intervals during work of doctors, to shift several doctor's tasks to other medical professionals, to flexibly manage work time of female doctors and so on. There should be several situations to cause excessive work hours of doctors in cardiovascular health care such as keeping emergent care in 24 hours per day and 365 days per year to reduce mortality of acute cardiovascular disease, and continuous training and education of progressing technology in cardiovascular care. In this symposium, we will discuss about current status and problems in work style of doctors in cardiovascular health care and propose future directions of the reform with quality improvement of the care.

In our longevity society, cardiovascular diseases are increasing rapidly, its medical costs and medical resources are increasing. ICT and big data are expected to reduce them. Big data in medical field including receipt data, DPC (Diagnosis Procedure Combination), medical care information input to an electronic medical record, real-time patient information obtained from living body monitoring, and so on. Already, Japanese Circulation Society is promoting evaluation and analysis of the medical quality of cardiovascular diseases in Japan using JROAD-DPC data. Cardiovascular diseases often repeat recurrence and gradually progress. CLIDAS (The CLinical Deep Data Accumulation System) project is also in progress to obtain longitudinal information from electronic medical records using SS-MIX2 and MCDRS (Multi-purpose Clinical Data Repository System). Furthermore, EHR (Electronic Health Record) is considered to enable research and various medical support.
In this session, we will discuss the usefulness and current issues of utilization of ICT and big data on cardiovascular diseases and help them to develop into the next generation.

The development of medical devices in Japan is far behind that in the US. In particular, novel therapeutic devices developed in Japan are extremely rare. Advances in medical devices are remarkable. For example, Transcatheter Aortic Valve Implantation (TAVI) has made it possible to treat many patients who conventionally required open surgery with minimally invasive way, and TAVI is rapidly expanding its indications. It is important to note that TAVI is a device-dependent treatment, and that the importance of operator’s skill is lower in TAVI than in conventional open surgery. Most of the subjects presented at this congress are reports of treatment results, and reports of new therapeutic device developments are extremely rare. What is truly needed in Japan today is not the ones who use TAVI well or those who gather up the TAVI data and present them at a conference, but are those who seek to create new TAVI devices with their own hands. Of course, TAVI treatment has already reached the stage of completion, and it is impossible to make a new entry there. TAVI is an example, and we should go to another unexplored medical field. The human resources and infrastructure in medical device development in Japan are poor compared to the US, but we should make a first step. In this session, we will introduce the trial of Japanese researchers who are developing original medical devices. I hope this session will encourage those researchers.

Patients with diabetes are often complicated with heart failure. Once diabetic patient manifests heart failure symptoms, his/her prognosis become worse. It is called “diabetic cardiomyopathy” when diabetic patient has a reduced cardiac function without evident coronary artery disease or other forms of cardiomyopathy. The mechanism of diabetic cardiomyopathy is believed quite complicated and it comes from metabolic disorders and mitochondrial damage of cardiomyocytes, vascular rarefaction, and tissue fibrosis etc. In this joint symposium, we will discuss the mechanisms and therapeutic targets of diabetic cardiomyopathy.

Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome, of which mechanism has not been clarified.  That’s why specific treatment methods have not been developed.  Given that HFpEF is common in elderly women with history of hypertension and left ventricular diastolic dysfunction, these factors are assumed to be relating to pathogenesis of HFpEF.
In this symposium, to better understand the pathophysiology of HFpEF, we want to discuss common features and different findings of HFpEF in respect to clinical characteristics between patients in USA and Japan, and recent topics concerning the molecular mechanism of HFpEF.

Ventricular tachycardia (VT) that occurs in patients with structural heart disease (SHD) carries an elevated risk for sudden cardiac death (SCD), and implantable cardioverter-defibrillators (ICDs) are the mainstay of therapy. In these patients, catheter ablation can be used as adjunctive therapy to treat or prevent repetitive ICD therapies. In patients with SHD, the main challenge for catheter ablation of VT is the complex arrhythmogenicity of the myocardial scar. Electroanatomical remodeling of the scar that occurs in SHDs prompt arrhythmias through different mechanisms. The potential for myocardial scar involving the midwall and epicardial surface of the ventricles further complicates the assessment of the arrhythmic substrate. The clinical correlation of this complex arrhythmia substrate is the high rate of VT recurrence after ablation, especially in patients with nonischemic cardiomyopathy. In order to improve the outcomes of ablation, new strategies of substrate ablation have been proposed that aim to perform selective ablation of the scar-related VT. In this session, we want to discuss the advantage and limitations of new strategies.

Coronary imaging supports safe and effective coronary intervention as well as scientific understanding of coronary artery disease and atherosclerosis. Coronary imaging modality has variety including intravascular ultrasound (IVUS) and optical coherent tomography (OCT/OFDI). OCT/OFDI can detect 10 micrometer size. Thus, we can see thin neointima over stent struts and thin cap over necrotic core. IVUS guided PCI has advanced because of safe and predictable outcome. Shorter antiplatelet therapy can be feasible in excellent coronary dilatation under IVUS guided PCI. In this session, we understand advancement of coronary imaging and the roles for better outcome in PCI.

Echocardiography has a central role in managements of various heart diseases by providing information about hemodynamics as well as cardiac morphology. However, it has some disadvantages, such as limited accuracy and reproducibility of quantification. Recently, advances in image quality of 3D echocardiography and automated quantification increase the usefulness of echocardiography in clinical practice. In addition, new technology for visualization of intracardiac flow and fusion imaging with other imaging modalities also enhance the utility of echocardiography for the management of heart failure and structural heart diseases.
In this session, progress in echocardiography and future prospects in the managements of various heart diseases will be discussed.