Program

Coronary revascularization is an established treatment for acute coronary syndrome (ACS), but the indications and choice of treatment for stable coronary artery disease (Stable CAD) are still under debate. The European Society of Cardiology has redefined traditional stable coronary artery disease as chronic coronary syndrome (CCS) and has divided CCS into six subtypes based on the patient's clinical background. Coronary revascularization is indicated for all subtypes except INOCA (CCS V), but the indications and choice of treatment for each subtype need to be constructed based on evidence, taking into account the anatomical and functional evaluation of coronary lesions. Furthermore, it has become clear that cardiac events in CCS patients are caused not only by ischemic attacks or ACS due to physiologically significant coronary lesions at the time of revascularization, but also by many factors such as ACS due to progression or rupture of non-significant lesions, ventricular arrhythmias, and heart failure. This session aims to deepen understanding of the application and selection of revascularization for CCS patients based on the results of recent clinical trials such as the ISCHEMIA trial, the STICH trial for ischemic heart failure, and the REVIVED-BCIS2 trial, as well as the guidelines and the latest findings.

The mortality rate for myocardial infarction, except for Killip IV, has significantly decreased due to the widespread adoption of early reperfusion therapy, particularly stent treatment. In our country, where over 90% of patients are eligible for stent treatment, the in-hospital mortality rate has improved to below 5%. However, cardiogenic shock associated with acute myocardial infarction remains a severe condition with an in-hospital mortality rate of up to 50% even today. Although many clinical trials, including randomized trials using mechanical circulatory support devices such as IABP and ECMO, have been conducted, no clear improvement in mortality rates has been observed until now. Among mechanical circulatory support devices, the Impella, which can strongly unload the left ventricle, has shown promising signs of improving survival rates in the randomized DanGer Shock trial and several registry data. At the same time, the increasing incidence of complications associated with its use is becoming apparent, posing a clinical challenge in balancing these factors.

In this symposium, we aim to clarify the issues surrounding acute myocardial infarction with shock and particularly discuss the use of mechanical circulatory support. By sharing valuable insights based on the latest research findings and clinical experiences, we hope to gain new perspectives that will enable us, as medical professionals, to provide more effective treatments.

Most thrombi responsible for cardiogenic cerebral emboli are derived from the ones formed in the left atrial appendage (LAA). Management of the LAA has been a topic of hot discussion. In a landmark study published in the New England Journal of Medicine in 2021, the LAAOS III trial showed a significant reduction in the incidence of stroke or systemic embolism as a primary outcome in patients with atrial fibrillation undergoing cardiac surgery for any major indication when surgical LAA closure was performed as a concomitant procedure, compared to patients who did not undergo LAA closure. Subsequent subanalysis of follow-up studies over a 5-year period demonstrated that surgical LAA closure reduced the risk of thromboembolism, with or without continuation of oral anticoagulants. The significance of such a large prospective randomized controlled trial validation is noteworthy. On this basis, further clinical questions naturally arise. What is the efficacy of LAA as a stand-alone procedure in the absence of comorbid cardiac disease such as valvular disease or coronary artery disease? There are many issues to be addressed in the future, including a comparison of the efficacy of open versus thoracoscopy-assisted LAA closure, endovasscular versus surgical LAA closure, and evaluation of thromboembolism when combined with pulmonary vein isolation or the Maze procedure. We would like to call real-world data from each institution on these issues so that we can gain a clearer picture of these issues.

Sudden cardiac death (SCD) in Japan exceeds 80,000 cases per year, remaining a significant social issue. The widespread distribution and usage of an automated external defibrillator (AED) has improved the survival rate of SCD, but there are several limitations to its effectiveness due to the conditions that a witness must be present at the event and the AED must be used correctly.

Recent advances in technology are considered useful for addressing SCD. The first application of these technologies is to assess the risk of SCD, especially by applying machine learning and deep learning to various types of information. In addition to the traditional search for single gene mutations, progress is being made in genetic risk assessment through the analysis of single nucleotide polymorphisms. In addition, research is progressing to evaluate the risk of lethal arrhythmias from conventional 12-lead electrocardiograms. Additionally, attempts are being made to improve the precision of risk assessments by integrating evaluations from multiple modalities. The second application involves monitoring using wearable devices. Currently, various technologies are being developed to track biological signals including heart rate or pulse rate. Using these data, systems are being researched to detect SCD attack and give prompt notice. Furthermore, technology to predict near-future events is being developed from long-term recorded heart rate data obtained from wearable devices and Holter ECG. With integration with the risk assessment for SCD from genetic analysis and 12-lead ECG may improve the accuracy of these algorithm.

In this symposium, we look forward to extensive discussions on the latest analytical methods and advances in medical devices and their applications aimed at preventing SCD.

The development of atrial fibrillation (AF) and heart failure are correlated and exacerbate each other. The management of AF in severe heart failure includes acute management in the intensive care unit as well as long-term treatment in the chronic phase.

In intensive care, the onset of AF can lead to hemodynamic compromise, caused by tachycardia and mitral regurgitation. Beta-blockers and antiarrhythmic agents are often challenging to administer due to the risk of hypotension and negative inotropic effects. Cardioversion was sometimes ineffective with a high recurrence rate due to elevated left atrial pressure and excessive sympathetic activity.

Non-pharmacological treatment options for AF include catheter ablation and creating atrioventricular block, followed by biventricular pacing, or conduction system pacing. However, these interventions are typically considered after the acute phase, and there is limited data on their feasibility in patients with severe heart failure exacerbations due to AF.

Recent evidence has highlighted the efficacy of ablation in patients with end-stage heart failure during the chronic phase. However, the success rate of ablation in cases of heart failure with an enlarged left atrium is not consistently satisfied.

A decrease in left atrial diameter by maintaining sinus rhythm can control atrial functional MR. But the question is which procedure should have priority, catheter ablation or percutaneous mitral valve repair with MitraClip?

In this plenary session, we will discuss both acute and chronic management strategies for AF in patients with severe heart failure.

The number of patients with heart failure with preserved ejection fraction　(HFpEF) is increasing with the advent of a super-aging society, and the proportion of HFpEF patients among all heart failure patients in Japan has exceeded the proportion of patients with heart failure with reduced ejection fraction (HFrEF). The prognosis for HFpEF is as poor as that of HFrEF, but the lack of clear evidence of pharmacological treatment enable to reduce mortality in HFpEF has long been a problem. Against this background, large clinical trials have recently shown that SGLT2 inhibitors significantly reduce the composite endpoint of heart failure events and cardiovascular death in a population of patients with non-HFrEF, including patients with HFpEF. It was also shown that several classes of drugs may be effective in some sub-groups of HFpEF patients. As a result, the therapeutic approach to HFpEF is changing significantly. On the other hand, the fact that HFpEF is a highly heterogeneous syndrome associated with various comorbidities and pathologies is considered to be one of the reasons why it is difficult to show the improvement of survival in HFpEF on drug therapy. It is also recognized that it is important to consider HFpEF as a phenotype of multimorbidity and to conduct comprehensive management that takes into account individual pathologies and comorbidities. In this session, we would like to discuss treatment strategies based on the pathophysiology and comorbidities of HFpEF, including the perspective of HFpEF as a multimorbidity.

The nomenclature as “cardiorenal anemia iron deficiency syndrome　(CRAIDS)” reflects the history of research and treatment of organ interactions between the heart and kidney.

The concept of cardiorenal interactions began with epidemiological data showing that many patients with end-stage renal failure died of cardiovascular causes, not due to deterioration of renal function, finally leading to the widespread diagnostic criteria for chronic kidney disease. Afterwards, the concept of cardiorenal syndrome composing the 5 disease types was proposed based on causal relationships and pathological phases. Among these, it has been pointed out that acute kidney injury during acute heart failure is influenced not only by a decrease in renal perfusion but also by renal congestion, and the staffs in intensive care units are still exploring optimization of body fluid balance in daily clinical practice. On the other hand, anemia has been well known as a complication of both renal and heart failure, deeply involved in the pathology and poor prognosis. Subsequent investigations for heart failure patients have showed that not the correction of hemoglobin by erythropoietin stimulating agents but the iron supplementation could improve their prognosis.

At present, the causal relationships among the components of CRAIDS have not been fully elucidated, and in particular, clinical feedback into actual practice remains a major challenge.

Echocardiographic assessments of left ventricular (LV) systolic and diastolic function or filling pressure are important for heart failure diagnostics. The Japanese Circulation Society (JCS), American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) recommend to use the three key parameters such as E/e', left atrial volume index (LAVi) and tricuspid velocity (TRV) in assessing LV diastolic function and filling pressure. Although there are indeterminate cases with these key parameters, left atrial strain is applicable to identify LV diastolic function and filling pressure as a supplementary diagnostic parameter.

Most patients with heart failure with preserved ejection fraction (HFpEF) complaint of exertional dyspnea. Resting echocardiographic examination or left atrial strain cannot reach diagnosis of some patients having HFpEF. Exercise echocardiography is helpful to diagnose patients with HFpEF by estimating elevated filling pressure during exercise. According to a recent study, an artificial intelligence (AI) provides diagnostic capability to estimate filling pressure. A new guideline for evaluating LV diastolic function and filling pressure will be introduced in the near future. In this session. we would like to discuss about the latest clinical investigations and future perspectives for better diagnosis of LV diastolic function by echocardiography.

Hypertension is a significant risk factor for cardiovascular disease, and its control, especially prevention, is a critical public health issue. Recent advances in 'Digital Hypertension.' have introduced artificial intelligence (AI), wearable devices, and therapeutic assistance applications into hypertension management, opening new application areas. 'Digital Hypertension' is expected to enable real-time blood pressure monitoring, data analysis, and personalized treatment guidance for individual patients, improving their ability to self-manage. Predictive models using AI technology can predict patients' blood pressure fluctuations and assist in detecting abnormal values early. Wearable devices facilitate continuous blood pressure measurement and provide immediate feedback on data. In addition, therapeutic aid applications can act as behavior-change tools to promote patient lifestyle improvements and help improve drug treatment compliance. In this plenary session, the usefulness and challenges of Digital Hypertension will be specifically discussed based on the latest research findings and real-life clinical examples. It will also look at how future technological innovations will transform the management of hypertension and ultimately contribute to the prevention of cardiovascular disease.

In recent years, preconception care has attracted particular attention, defined as initiatives aimed at encouraging women and couples to take care of their health in preparation for future pregnancies. For women with heart disease, the issue of pregnancy arises after the AYA generation. In certain instances, such as when a woman has had a heart condition since childhood and has always believed that she cannot get pregnant, or when a woman has a heart condition that poses a significant risk to pregnancy but believes that she will be fine, it is necessary to provide appropriate medical advice. It is of the utmost importance to be aware of the potential consequences of pregnancy in order to make informed decisions. One specific benefit is that it avoids unnecessary abortions. In some cases, an abortion may be chosen if continuing the pregnancy would be dangerous to the mother's life. This carries a significant mental and physical burden. Conversely, there are also cases where the possibility of pregnancy can be indicated. Another major benefit of preconception care is that it allows for tests to be avoided during pregnancy, and it also allows for drugs to be changed in advance that should be avoided during pregnancy. From a psychological perspective, it is also important to remove some of the anxiety associated with pregnancy in advance. Evaluating cardiac function before pregnancy can also contribute significantly to the information sharing and management planning by multidisciplinary specialists when managing a pregnancy.

In this session, we will discuss the current state of preconception care for women with heart disease, as well as the issues involved, with the aim of sharing what should be done.

The heart, which continues to beat throughout our lives, has an exceptionally active cycle of intracellular energy production and consumption. In cardiomyocytes, abundant mitochondria actively produce ATP, which is immediately consumed for myocardial contraction. Mitochondrial abnormalities induce a disruption of this energy production pathway, leading to energy depletion and increased oxidative stress. This results in reduced myocardial contractility, chronic inflammation, cell death, and ultimately, cardiac dysfunction and the onset of heart failure. Moreover, in damaged myocardium, there is a shift in energy substrates from fatty acids to glucose. The excessive accumulation of unused fatty acids can cause lipotoxicity, while inhibition of fatty acid uptake may contribute to worsening heart failure. Thus, the relevance of substrate shifts in heart failure remains unclear. Recently, the effectiveness of SGLT2 inhibitors in heart failure has drawn attention to other energy substrates, such as ketone bodies and amino acids. In addition, research is progressing on understanding the metabolic interactions between the heart and adipose tissue surrounding the heart and throughout the body, as well as the development of animal models crucial for unraveling the complex pathophysiological mechanisms. In this session, outstanding researchers in the cardio-metabolic research field will present how energy metabolism affects the onset and progression of heart failure based on the latest research findings. They will also discuss the potential for new treatments for heart failure. We eagerly anticipate exploring together the potential that energy metabolism research holds in paving the way for the future of heart failure treatment.

“Nucleic acid drugs" are attracting attention as a "third drug" following general "low-molecular drugs" and "antibody drugs" used in immunotherapy for cancer.

Nucleic acid drugs are chemically modified nucleotide-based drugs manufactured through chemical synthesis. Typical nucleic acid drugs that have been developed include antisense oligonucleotides (ASOs), small interference RNA (siRNA), aptamers, and decoys. Nucleic acid drugs are expected to be a new drug discovery modality for diseases that are difficult to treat with conventional drugs, because they have high specificity for their targets and can target intracellular molecules such as messenger RNA (mRNA) and non-coding RNA that are difficult to target with conventional drugs. In addition, because they are chemically synthesized products, it is easy to obtain candidates in a relatively short time, and their practical application as next-generation pharmaceuticals is progressing.

Moreover, systems for delivering these nucleic acid drugs to target organs and cells are being improved day by day, contributing to improved safety and efficacy of the drugs.

In this plenary session, many experts will explain in detail about this area where new drugs are being created one after another. This will give you a sense of the speed at which technology is advancing. It is expected that the global research and development in this field, including Japan, will continue to be active in the future.

In the Society 5.0 concept for medical and healthcare by the Cabinet Office of Japan, in addition to the dataization of medical information through the spread of electronic medical records, the evolution of information technology enables the dataization of the human body, physiological functions, and behavior. The goal is to provide personalized medical care through artificial intelligence (AI) analysis of the “medical digital twin” collected in the cloud.

Currently, however, integration of disease-specific medical information into electronic medical records is insufficient, and it is not easy to incorporate data from patients' own personal health records (PHRs) and wearable devices into electronic medical records or to integrate such information into a medical digital twin. In Japan, the Cabinet Office's Strategic Innovation Promotion Program Phase 3, “Building an Integrated Healthcare System,” in collaboration with the Japanese Society of Cardiology, aims to establish a medical digital twin by integrating a multimodal data, develop generative AI based on this foundation, discover new medical knowledge, and develop social implementation solutions.

In this session, we will introduce advanced research and development efforts, including the utilization of medical big data and wearable device data, machine learning, and the application of generative AI, and look forward to a medical version of society 5.0.

Ischemic heart disease (IHD), also known as coronary artery disease, remains the leading cause of death worldwide. According to the Global Burden of Disease Study, IHD accounted for approximately 16% of all deaths globally in 2021. It is well established that IHD is primarily caused by atherosclerosis development due to the complex process of endothelial injury, lipid accumulation, plaque formation and progression, and plaque instability and rupture. Given the pathogenesis of IHD, lipid-lowering therapy such as statins and PCSK9 inhibitors, is a cornerstone in the management of IHD, aimed at reducing the levels of atherogenic lipoproteins, primarily low-density lipoprotein cholesterol (LDL-C). While lipid-lowering therapy are highly effective in reducing the risk of major cardiovascular events, there remains a "residual risk" of cardiovascular disease even in patients who achieve optimal LDL-C levels with lipid-lowering therapy. Addressing this requires a comprehensive approach that includes combination pharmacotherapy, targeting additional risk factors like inflammation and triglycerides. In this symposium, we’d like to explore the latest insights and advancements in the diagnosis and treatment of non-atherosclerotic ischemic heart disease during a symposium.

Unphysiologically-high shear stress is generated in blood stream in patients with aortic stenosis (AS), implantation of left ventricular assist device and so on, which strongly enhances a risk of bleeding, especially in gastrointestinal tract.　When AS patients combine gastrointestinal bleeding, this combination disease is called Heyed’s syndrome, according to the name of the first doctor reporting the disease combination. It is, today, considered that the bleeding is typically from gastrointestinal angiodysplasia that is fragile abnormal vessels developed immediately underneath the mucosa under acquired von Willebrand syndrome (AVWS), a hemostatic disorder. On the other hand, V-A ECMO and Impella also cause more severe AVWS than that in AS patients. Sometimes bleeding becomes critical for the continuation of these treatment.

von Willebrand factors（VWFs）are generated as giant multimers and cleaved in a shear-stress dependent manner and present in blood as multimers consisted of 2-80 VWF subunits. Importantly, it is known that higher molecular weight VWF multimers play more critical roles in hemostasis. Thus, unphysiologically-high shear stress causes AVWS by enhanced cleavage of VWF multimers. Recently, VWF high molecular weight multimers has been evaluated quantitatively and clinical features of cardiovascular disease-associated AVWS have been understood more clearly. On the other hand, while the clinical features of gastrointestinal angiodysplasia have been unclear, it has also been evaluated systematically. In this symposium, we aim to deepen understandings on bleedings, especially gastrointestinal bleeding, associated with cardiovascular diseases with excessively-high shear stress and mechanical circulatory device by accumulating recent findings.

In contrast to type A aortic dissection, which is treated with emergency surgery, type B aortic dissection (TBAD) is treated with medical therapy, but the short- and long-term prognosis is not favorable. Acute complications such as aortic rupture and visceral ischemia are the main causes of the poor short-term prognosis, while aorta-related events associated with aortic enlargement in the chronic phase are the main factors worsening the long-term prognosis. While thoracic endovascular aortic repair (TEVAR) is the first-line treatment for patients with complicated TBAD, preemptive TEVAR is now widely performed to prevent future aorta-related events in patients with uncomplicated TBAD. Although preemptive TEVAR is highly effective and is expected to improve the overall prognosis of patients with TBAD, there is little scientific evidence to support this approach. Furthermore, many centers are reluctant to perform the procedure due to the risk of fatal complications such as retrograde type A dissection. In short, the surgical indications for preemptive TEVAR for uncomplicated TBAD remain controversial and TEVAR is currently recommended only for high-risk patients, who are more likely to have a poor prognosis. On the other hand, TBAD itself has a variety of pathological anatomy, including the extent of dissection and false lumen thrombosis, and the therapeutic strategy must be based on a multifaceted understanding of the pathophysiology of the disease. In this symposium, we would like to discuss the pathogenesis, diagnosis, treatment, short- and long-term prognosis, and other aspects of TBAD from a scientific perspective, with the goal of creating a new consensus on how to diagnose and treat individual cases of TBAD.

The treatment strategy for comprehensive chronic limb-threatening ischemia (CLTI) is determined by the general condition, wound severity, and anatomical complexity. Guidelines based on the results of the BASIL 1 trial have recommended bypass surgery (BSX) as the first-line therapy for cases with an expected life expectancy of more than 2 years and usable autologous veins since this study was published in 2005 and 2010. Recently two randomized controlled trials for the treatment of CLTI have been reported. In the BEST-CLI trial, for CLTI patients with usable autologous veins, BSX showed better outcomes than endovascular therapy (EVT), while in those without usable autologous veins, outcomes of BSX and EVT were comparable. On the other hand, the BASIL 2 trial targeting CLTI complicated with below-the-knee arteries showed better outcomes with EVT compared to BSX. Based on these evidences, we are at a crossroads in the framework of treatment strategies for CLTI patients unique to Japan. It is hoped that the discussions at this symposium will contribute to addressing current issues and serve as a guide to future innovative treatment strategies.

In recent years, as knowledge of cardiac electrophysiology has deepened, advances in 3D mapping systems have clarified various tachyarrhythmia mechanisms and made it easier to identify target sites for ablation. New treatment modalities, such as pulsed field ablation and radiation therapy, are also being developed. In the treatment of devices such as ICDs for lethal ventricular arrhythmias, devices are being developed that are compact, long-lasting, highly diagnostic and can be used in heart failure. In bradycardia pacing, there is also a paradigm shift from traditional right ventricular apex pacing to newer methods such as conduction system pacing, which provides physiological ventricular contraction. Thus, while recent advances in arrhythmia diagnosis and treatment are remarkable, we as clinicians have a responsibility to clarify not only the light but also the dark side. In this session, we would like to deepen our knowledge of the most advanced and up-to-date therapies and medical devices that are currently being used or will be used in the treatment of arrhythmias, and to determine the current status and future of arrhythmia treatment.

Early detection of atrial fibrillation is critical to prevent adverse events of atrial fibrillation such as cerebral infarction and heart failure. In recent years, various attempts have been made for the early detection of atrial fibrillation through advances in various atrial fibrillation detection devices such as portable electrocardiographs, long-time electrocardiographs, Apple Watch, and implantable electrocardiography, as well as biomarker, genetic, and AI analysis. However, no conclusion has yet been reached as to how much intervention in the severity of atrial fibrillation cases that have been identified will improve prognosis. The ultimate goal is the prevention of this disease, but further study is needed.

Atrial fibrillation is a common arrhythmia in elderly patients with comorbidities, and it requires ingenuity in anticoagulation and drug therapy, which must be tailored to the patient's condition. Among atrial fibrillation cases, there are challenging cases such as tachycardia-induced cardiomyopathy and atrial fibrillation complicated by cardiomyopathy. The timing and targets of atrial fibrillation ablation have changed as atrial fibrillation ablation has advanced dramatically, with improved results in pulmonary vein isolation and fewer complications. In this context, it is also important to consider how to handle difficult cases such as persistent atrial fibrillation and cases that do not originate in the pulmonary vein. How to utilize new technologies, including pulsed-field ablation, will also be important in the future.

In this symposium, we aim to discuss comprehensive treatment strategies for atrial fibrillation, from prevention and early detection to medical and interventional treatment, based on the presentations of the latest findings.

Treatment for chronic heart failure is evolving day by day, and in recent years, several new drugs supported by the results of large-scale clinical trials have been added as fundamental therapy. However, such EBM-based treatments are often based on patient data mainly from Caucasians, and may not match the representative phenotype of heart failure patients in Japan. In particular, it is a well-known fact that the phenotype of HFpEF differs significantly between East Asia and Europe or the United States, and it is an urgent task to find the optimal treatment for Japanese unique HFpEF phenotype in the future. This can be considered a kind of personalized medicine, but personalized medicine should originally seek individualization at a unit even smaller than race. Personalized medicine also includes predicting the response to drug therapy or device therapy with a high degree of accuracy using biomarkers or genetic testing. Identifying gene mutations that cause cardiomyopathy and moving toward gene therapy, regenerative medicine using my iPS cells, and even dealing with disease-specific iPS cells to select and develop more effective drugs can all be considered treatments that originate from individualization. This symposium will provide an opportunity to consider heart failure treatment on an individual basis, going beyond attempts to explore heart failure treatments specific to Japanese people.

Long-term home-based assisted ventricular therapy (Destination Therapy (DT)) in Japan started at seven facilities in April 2021, followed by 12 additional facilities in July 2023. The number of patients implanted with DT has steadily increased, and many patients have returned to society. As a result, DT plays an essential role in treating severe heart failure in Japan.

On the other hand, DT has several challenges. First, managing complications such as infection and thrombus becomes more difficult the longer the device is privately used. In addition, physical factors that impair the quality of life of DT patients, such as deteriorating right ventricular or renal function, cannot be fully predicted.

Furthermore, there needs to be an even distribution of facilities nationwide where devices can be implanted and managed. Even in regions where treatment facilities are available, more than support systems for patients with an artificial heart and their families, home care and emergency response systems are needed. In addition, how patients implanted with artificial hearts are accepted by society has yet to be defined, and social support, such as return to work, is required.

Thus, many medical and social issues remain in DT medicine. However, this also means that DT treatment could be better. In this symposium, we would like to have a lively discussion on how we can provide more beneficial DT medicine to patients.

Disease management by a multidisciplinary team is important from the viewpoint of preventing exacerbations, which greatly affects the quality of life of patients with heart failure (HF), and has become one of the core components of HF treatment since it was proposed in the guidelines. On the other hand, patients with HF, especially elderly patients, have many complex problems not only medically but also socially, such as cognitive dysfunction, frailty, sarcopenia, low nutrition, polypharmacy, depression, and lack of caregiving ability due to living alone. The importance of home medical care and community collaboration is obvious in order to maintain home care time after patients with HF are discharged from the hospital, but it is still in its infancy. Furthermore, HF disease management covers all stages of HF, and it is necessary to promote awareness of HF among patients, their families, and society. Initiatives are underway that are expected to spread and improve the quality of HF disease management, such as the birth of 　Certified　Heart　Failure　Educator by the Japanese Circulation Society, early detection of HF exacerbations, use of the Internet of Things (loT) in regional multidisciplinary cooperation, and the model project for Stroke and Cardiovascular Diseases Support Center. In this session, we look forward to a discussion based on pioneering case studies and evidence on how disease management can respond to the complex problems faced by HF patients and the challenges of current medical care system and society.

Cardiac CT has rapidly evolved in recent years and play an important role in diagnosis and treatment of cardiovascular diseases. It has become an essential tool in patient evaluation and treatment planning because it is noninvasive, has high resolution, and provides detailed information about the heart and coronary arteries. Coronary CT angiography provides a variety of information, including assessment of coronary artery anatomy, degree of stenosis, and plaque characteristics. In addition, recent guidelines for the treatment of ischemic heart disease emphasize the role of coronary CT and its importance in determining treatment strategy. The recent advent of photon-counting CT is expected to provide more precise images with higher spatial resolution and lower exposure compared to conventional CT. Furthermore, with the advent of upright CT, the evaluation of the venous system is also becoming possible. In addition, with the development of transcatheter therapy for structural heart disease, cardiac CT has demonstrated its utility as a form of multimodality imaging in structural heart disease. Thus, with the technological innovation and research progress in cardiac CT, its application is expanding more and more. In this symposium, we would like to focus on the latest technologies and applications of cardiac CT, including AI, and discuss its current status and future prospects with you in depth.

In 2023, the JCS/CVIT/JCC Guideline Focus Update Edition Diagnosis and Treatment of Coronary Spasm Angina and Coronary Microcirculatory Disorders was published. Ischemia with nonobstructive coronary artery disease (INOCA) is a concept proposed by the United States in 2017. However, it is defined as a patient with no significant organic stenosis in the coronary artery. The Endotype of INOCA is a condition that causes coronary spasm and coronary microcirculation disorder (CMD) without stenosis of the epicardial coronary artery, so it includes vasospastic angina, coronary microvasospasm, and microvascular angina. It is more complex because there is also some overlap between these.

Invasive diagnostic methods using catheter tests have been proposed for coronary spasm and CMD in other countries, but these methods are not standardized from the viewpoint of safety and cost-effectiveness. On the other hand, non-invasive diagnostic methods include quantitative evaluation of myocardial blood flow using cardiac MRI or PET with excellent spatial resolution, CT to exclude significant stenotic coronary artery lesions, and metabolic evaluation using fatty acid metabolism SPECT in Japan. Furthermore, vascular endothelial function tests can also be performed. In this symposium, we would like to approach comprehensive diagnostic methods for INOCA that are suitable for clinical practice through lectures by leading experts in various modalities. We look forward to the participation of many audience members.

Transcatheter aortic valve implantation has been established as a valid therapeutic option for patients with aortic stenosis.

Transcatheter mitral and tricuspid treatment are also emerging with rapid progress. Advancement of left appendage closure and adult congenital disease are also rapidly evolving fields. In this session, the current status and future perspectives of this field will be presented based on real-world data.

TAVI has now surpassed surgical valve replacement (SAVR) as an invasive treatment for aortic stenosis. This year, the results of TAVI in patients at low surgical risk were reported to be non-inferior to that of SAVR at one year of follow-up. This report is based on a very short period of time, and there are some problems, such as more additional procedures in the SAVR group and a large number of biological valves that have already been eliminated from the market. However, the range of indications for TAVI is likely to expand in the future. Yet, the durability of TAVI is not yet clear, and the use of bioprosthetic valves, which are expected to be durable for 10-15 years, is certainly worthwhile. On the other hand, as the number of TAVI cases increases, it has been shown that SAVR after TAVI is not easy and that there are various problems with the so-called Valve in Valve after SAVR. In addition, the limitations of TAVI in terms of prognostic improvement have been pointed out in hemodialysis patients. The possibility of TAVI treatment for aortic regurgitation has also been reported, and aortic valvuloplasty is finally becoming a standard procedure, with results that surpass those of biological valves. There is no doubt that an appropriate combination of aortic valvuloplasty, SAVR, and TAVI will provide the greatest benefit to patients with aortic valve disease.

In this session, we would like to report the current status of the latest invasive treatment of aortic valve disease and discuss what is the appropriate treatment for the patient.

Surgery for the tricuspid valve must be considered separately as tricuspid valve surgery performed simultaneously with left-sided valvular disease, and isolated tricuspid valve surgery for severe tricuspid regurgitation (TR).

The question of whether or not to add tricuspid valve repair to the left-sided valvular disease is an eternal theme for surgeons. In the 2000s, if the tricuspid annular diameter was 35 or 40 mm (21 mm/m2) or more on transthoracic echocardiography or 70 mm or more on intraoperative findings, it has been recommended to add tricuspid valve repair regardless of the TR grade. However, with preoperative 3D transesophageal echocardiography becoming routine and the number of small incision surgeries using endoscopes increasing, it cannot be denied that this standard is becoming outdated.

On the other hand, it is known that isolated tricuspid valve surgery for severe TR has a worse prognosis than normal left-sided valvular disease. It is expected that catheter treatment will be introduced soon. In addition, surgical procedures that take right ventricular function into consideration have been proposed. Under these circumstances, the timing and method of intervention to the tricuspid valve have recently become actively discussed. New findings about the tricuspid valve have been obtained through 3D echocardiography and other imaging modalities, and discussion is also deepening regarding right ventricular function, which is likely closely related to postoperative prognosis.

We would like to have a lively discussion in the heart team about the tricuspid valve, which will likely become a major issue in an aging society.

Declining birthrate and aging population have caused simultaneous progress in decreased labor force population and increased nursing care-requiring population. These problems are placing a heavy burden on Japan's people and society. As a countermeasure, the “Japanese National Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular Disease” was formulated, and according to the fundamental plan, the first phase 5-year plan has been conducted and the second phase is ongoing. In the fundamental plan, the importance of seamless rehabilitation from the acute phase to the maintenance phase was emphasized, and this might have accelerated regional cooperation in cardiac rehabilitation.

Starting rehabilitation as soon as possible from the hyperacute stage of ICU/CCU stay is also important to prevent placing patients in disadvantageous situations due to excessive rest, and to maintain and improve QOL/ADL, especially in the case of elderly patients with a cardiovascular disease.

In this symposium, some of the advanced attempts and achievements of community-based comprehensive cardiac rehabilitation will be presented, and then, the issues that have become clearer and future prospects will be discussed.

Recent evidence suggests that acute coronary syndrome (ACS) is caused by acute thrombosis of coronary artery. Thrombosis results from rupture or erosion of atherosclerotic lesions, which cause mild narrowing of the lumen. Vulnerable plaques are pathologically characterized by positive remodeling, increased lipid content, thinning of fibrous cap, decreased smooth muscle cell content, and decreased collagen content. Efforts have been made to detect vulnerable plaques by using biomarkers or imaging techniques, but there is no established method to predicate ACS accurately.

Various activated inflammatory cells, apoptosis of smooth muscle cells, degradation of collagen by matrix metalloproteinase, increased coagulability by increased expression of tissue factor and PAI-1, intra-plaque hemorrhage are reported to play important roles in the pathogenesis of plaque instability. However, the molecular mechanism of chronic sterile inflammation in the vasculature and plaque destabilization is not fully understood. It was suggested that chronic infection of periodontopathic bacteria and/or helicobacter pylori was associated with atherosclerotic diseases.

In this symposium, we would like to discuss the association between atherosclerotic diseases and oral health, focusing on significance of oral care to prevent cardiovascular diseases.

The ESC/ERS guideline for pulmonary hypertension (PH) was revised in 2022, followed by the 7th World Symposium on Pulmonary Hypertension in Barcelona in 2024. With regard to the treatment of pulmonary arterial hypertension (PAH), clinical trials of sotatercept and new drugs have been done, and approval of new drugs based on other pathways in addition to the traditional three pathways is expected. On the other hand, severe PAH resulting in right heart failure still requires continuous intravenous epoprostenol and finally lung transplantation. In chronic thromboembolic pulmonary hypertension (CTEPH), accumulation evidence regarding the efficacy and safety of balloon pulmonary angioplasty (BPA), anticoagulation, and pulmonary vasodilators have been explored in Japan.

Furthermore, clinical studies on the safety and efficacy of BPA for symptomatic chronic thromboembolic pulmonary disease (CTEPD) without PH are also ongoing in Japan. In this symposium, we would like to invite presentation regarding the pathogenesis, novel diagnosis tool and treatment strategy for PH and RV failure, and provide an opportunity to discuss the challenges and prospects in the field of PH in the future.

Congenital heart disease occurs at a frequency of 5 to 10 per 1,000 live births and is one of the leading causes of neonatal and infant mortality. With advances in pediatric cardiology and pediatric cardiovascular surgery, the number of adult patients with congenital heart disease who have survived childhood continues to increase and now represents a major area of adult cardiology. Congenital heart disease, with its complex structural abnormalities, is not completely cured in childhood, but rather presents a variety of problems in adulthood, including inheritance to the next generation. Of all congenital heart diseases, 60% are due to multifactorial inheritance, while 15% are reported to be caused by gene copy number variants, 13% by chromosomal abnormalities, and 12% by single gene disorders, often recognized as complications of chromosomal and congenital anomaly syndromes. In recent years, the responsible genes for chromosomal abnormalities and congenital anomaly syndromes have been successfully identified, contributing to the elucidation of the pathogenic mechanism of congenital heart disease. On the other hand, even in congenital heart diseases that are not complicated by syndromes, advances in genetic analysis technology have led to the identification of candidate causative genes, and variants in genes encoding transcription factors, signal transduction factors, and structural proteins that are essential for cardiac development have been reported. The identification of genetic factors for these congenital heart diseases, including those in adults, by genetic testing is useful for genetic medicine and management of the diseases, and is expected to be extended to prevention and treatment of the diseases in the future. This symposium will present cutting-edge research by leading international researchers related to genetic medicine for pediatric and adult congenital heart disease.

The history of gender-specific medicine begins with a negative chapter in the 1970s when women were excluded from clinical medical and pharmaceutical research due to concerns about fertility, leading to a lack of female data. However, from the 1980s onwards, a policy shift emphasized the need to study conditions unique to women across all ages. This led to the development of modern gender-specific medicine, which focuses on diseases where differences in biological sex impact incidence rates, severity, and disease progression, creating an interdisciplinary field.

In Japan, the Japanese Circulation Society released the first "Guidelines on Gender-Specific Medicine in the Cardiovascular Field" in 2010. Considering societal changes and the accumulation of evidence, these guidelines were revised this year for the first time in 14 years, now titled the "Guidelines for Cardiovascular Care with Consideration for Diversity." While understanding and movements towards societal diversity have gained attention over time, and the importance and necessity of gender-specific medicine are increasingly recognized, there remains a significant lack of sufficient evidence.

In this session, we will discuss the development, current issues, and future directions for building evidence in gender-specific medicine. By engaging experts, we aim to explore how to practically incorporate these principles into cardiovascular care in Japan, focusing on the current status and implementation of gender-specific medical practices.

There are high expectations for cardiovascular regenerative medicine for refractory heart failure and critical limb ischemia. Various options are now available, including human iPS cells, mesenchymal cells, gene therapy, and nucleic acid medicine. In this symposium, under the theme of "Cardiovascular Regenerative Medicine," we would like to hear cutting-edge research results from a variety of researchers, from those who are currently conducting clinical studies and trials to those who are conducting basic research for future clinical applications. We look forward to receiving applications from many researchers.

With the remarkable progress in cancer therapy, management of cardiovascular risk factors and cancer therapy-related cardiovascular toxicities has a major impact on prognosis and QOL of cancer patients and survivors. In addition, a history of cancer is a significant risk for future development of cardiovascular diseases, and the need for long-term cardiovascular monitoring is increasing for cancer survivors. Under such circumstances, the onco-cardiology services have been organized across medical departments, where oncologists and cardiologists collaborate interdisciplinarily with allied health professionals. In March 2023, the Onco-cardiology Guideline was first published in Japan, and specific recommendations were proposed for several clinical questions on the basis of expert consensus. However, the evidence in this field is not sufficient, due to the diverse treatment protocol of cancer chemotherapy and the complicated characteristics of patients (cancer subtypes, stages, and demographics). The Onco-cardiology Guideline is also expected to serve as a “bridgehead” for future accumulation of evidence from clinical trials and utilization of big data. In this symposium, we will introduce the essence of onco-cardiology management which cardiologist need to know, and discuss the problems and future directions toward bridging the evidence-practice gap in this field.

At this symposium, we look forward to the presentation of new medical care and technologies aimed at insured medical treatment from the perspective of cardiovascular medical professionals.

National medical expenditure in FY 2021 was approximately 45 trillion yen, with the largest number of major injuries and diseases being "cardiovascular diseases" at 6.1trillion yen (18.9% of the total), followed by "neoplasms < tumors>" at 4.8 trillion yen (14.9%), and "diseases of the musculoskeletal system and connective tissue" at 2.6 trillion yen (8.0%).
(https://www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/21/dl/kekka.pdf)

In Japan in developed countries with aging populations, our challenge is how to quickly deliver sustainable, safe and secure medical care. The Health Insurance Practice Committee of the Japanese Circulation Society is working with other cardiovascular societies to revise medical fees for new medical technologies, medical devices, and drugs. For the future development of cardiovascular medicine, we look forward to the development of necessary medical technologies and heated discussions toward insurance treatment.

With the increasing number of cardiovascular disease patients in a super-aged society, differentiated healthcare systems and collaboration between hospitals and clinics are becoming crucial. Therefore, it is essential to enhance cardiovascular care in local communities. However, alongside aging populations, there is a growing prevalence of comorbidities such as renal dysfunction, dementia, and difficulty in outpatient management due to sarcopenia-related physical decline. Issues such as living alone, elderly caregiving, and poverty also impact social determinants of health. These factors contribute to gaps between evidence-based guidelines and clinical practice. For instance, decisions regarding the extent of ARB or MRA administration for heart failure patients with renal dysfunction, and the introduction of new medications for impoverished or elderly patients living alone, pose challenges. Additionally, discrepancies arise when patient and family preferences do not align regarding device implantation. In this session, we aim to discuss instances of evidence practice gaps occurring in cardiovascular clinic settings in local communities, inviting healthcare professionals nationwide to join in the discourse.

The Ministry of Health, Labour and Welfare initiated the "Nōsotchū Shinzō-byō Tō Sōgō Shien Centers" as a model project in 2022, aiming to centralize support for cardiovascular disease patients. In its first year, the project involved 10 municipalities, expanding to 15 municipalities in 2023 and 12 in 2024. These centers, staffed with medical institutions possessing specialized knowledge, aim to strengthen collaboration with local medical facilities and prefectures to build a comprehensive support system. This session will discuss the reported examples and related challenges.

Under the Ministry of Health, Labour and Welfare's regional medical care initiative, the development of advanced acute medical care systems in each region is gradually progressing. There has also been an increase in the number of cases requiring advanced acute medical care owing to rapid aging. In addition, with the work style reformation for doctors beginning in April 2024, there is an urgent need for the rapid establishment and reorganization of the advanced acute medical care system. In densely populated areas, emergency PCI can be performed at many hospitals. In contrast, in non-densely populated areas, many are forced to transport STEMI cases to locations that require a significant amount of time. We would like to discuss what is necessary for the construction of an advanced acute medical care system as well as the current situation and problems in prefectures and regions.

On the other hand, the MC Council has rarely been discussed in the cardiovascular field, partly due to the fact that the physician-side members of the MC Council in prefectures and regions are mostly emergency medicine specialists, so in many cases, there are few cardiovascular physicians. Now that the usefulness of prehospital 12-lead electrocardiograms has become widely recognized, I believe that it is important for cardiologists to be closely involved in matters related to transportation from the emergency site to medical institutions. We would like to discuss a wide range of issues related to emergency cardiovascular transport, including the involvement of cardiologists in prefectural and regional MC councils, in order to smoothly manage emergency cardiovascular patients and strengthen cooperation with emergency teams.

In the treatment of severe cardiovascular disease, definitive therapy of the underlying disease and high-quality intensive care go hand in hand. Thus, it is especially significant for young cardiologists to learn about critical care.

This is a joint session between the JCS and the Japanese Society of Intensive Care Medicine. We first present the current status and issues of cardiovascular critical care as an introduction, and then discuss actual cardiovascular cases with cardiologists and intensive care physicians. This is a place to consider and learn how to utilize the latest knowledge in cardiovascular intensive care medicine for the management of modern critically ill patients, who have more complex pathologies and multi-organ damage than ever before. We would also like to discuss creating an environment where young cardiologists can learn critical care cardiology as a cardiovascular subspecialty.

We hope that this joint symposium will help improve the quality of cardiovascular critical care in Japan in the future.

Twenty years after the start of the AI revolution with Deep Learning, the use of AI technology has moved from the research phase to an era of widespread and generalized use in various medical fields in Japan and abroad, from diagnostic imaging to programmed medical devices for treatment. In the field of cardiovascular medicine, there has been a dramatic increase in reports related to echocardiography, coronary CT, and other imaging, as well as waveform data centered on electrocardiograms. In addition, many efforts have been initiated to realize personalized medicine, including genomic and omics information and information based on biomonitoring. In clinical research as well, a paradigm shift is underway, as evidenced by the initiation of a system in Japan , using large-scale language models such as ChatGPT ,to utilize large amounts of Real World Data for Clinical Randomized Trials (CRT) as a control group for rare diseases. In this symposium, we would like to introduce the latest domestic and international trends in the use of AI in the field of cardiovascular medicine in the new era of medical care and deepen the discussion on future prospects.

Understanding and reducing health and healthcare disparities has recently been a top priority in the US and other countries. Recognizing its significance, in 2024, the Japanese Circulation Society published “Guideline on Cardiovascular Practice with Consideration for Diversity, Equity, and Inclusion”. Interestingly, as Japan has a homogeneous population, universal healthcare coverage and high quality of care, health and healthcare disparities are relatively small, and the majority of studies shaping the guidelines originated from outside Japan. Diversity and disparities in health and healthcare also exist among countries, as demonstrated by country-level statistics from OECD and WHO. While direct comparative studies are limited, our recent study comparing heart failure care and outcomes in the US and Japan revealed better care and outcomes in Japan. The ultimate goal of diversity/disparity research is to promote health equity for all people and create healthcare systems that embrace diversity. Considering these goals and building on Japan’s unique successes in health and healthcare equity, we propose a new framework for diversity/disparity research that addresses diversity not only from the traditional perspective of 'within-country/among subgroups' but also 'among countries'. This session will focus on cardiovascular epidemiology, social determinants of health, quality of care, and education/quality of health professionals and discuss how to advance the science of diversity/disparity from both within-country and cross-country perspectives.