ISSN0535-1405

No. 511

May 31, 2022
Published by International Medical Society of Japan,Chairman, Board of Directors: Kenichi Ishibashi, MD, PhD
Editors: K. Ito, MD, PhD, T. Kondo, MD, PhD,K. Ichihashi, MD, PhD, T. Murakami, PhD, R.Nagai, MD, PhD,
I. Taniguchi, MD, PhD, and T. Yamazaki, MD, PhD
3F MK Sangenjaya Building, 1-15-3 Kamiuma, Setagaya-ku,Tokyo154-0011,Japan.
TEL 03(5486)0601 FAX 03(5486)0599 E-mail: imsj@imsj.or.jp https://www.imsj.or.jp/

The 453rd International Symposium on Therapy
The 453rd International Symposium on Therapy washeld by the Zoom Webinar on March 17, 2022. Dr.
Tsutomu Yamazaki, Director of the International
Medical Society of Japan (IMSJ), presided over themeeting.

New catheter treatment in the
cardiovascular field
Introductory Message from the Chair
Tsutomu Yamazaki, MD, PhD
Director, IMSJ
The program was structured with the following
theme: New catheter treatment in the
cardiovascular field.
Lectures were given by the following professors on
the following topics: Koichiro Sugimura, MD, PhD,Professor, Department of Cardiology, International
University of Health and Welfare, Narita Hospital,on Novel Therapeutic Approaches for Chronic
Thromboembolic Pulmonary Hypertension and Akio
Kawamura, Chairman and Professor, Departmentof Cardiology, International University of Healthand Welfare, School of Medicine, on Percutaneous
Closure of Patent Foramen Ovale.
Designated as an intractable disease, pulmonary
hypertension is common in young women. Amongthe various types of pulmonary hypertension,
chronic thromboembolic pulmonary hypertension,commonly referred to as CTEPH, is thought tohave a relatively good prognosis. Professor
Sugimura demonstrated that balloon pulmonary
angioplasty, which has been further developedin Japan following its initial development, haslargely contributed to the relatively good prognosis
of CTEPH. Professor Kawamura explained thatwhile paradoxical embolism caused by patent
foramen ovale is well known as a textbook topic,
it is also a significant clinical challenge as it isconsidered to be one of the causes of cerebral
infarction of undetermined cause in young adults.
He demonstrated that percutaneous closure
can be safely performed in a relatively short time
for treating patent foramen ovale. The lectures
enabled us to gain knowledge about the latest
advances in the rapidly advancing catheter
treatments.

LectureⅠ
Novel Therapeutic Approaches for
Chronic Thromboembolic Pulmonary
Hypertension
Koichiro Sugimura, MD, PhD
Professor
Department of Cardiology
International University of Health and Welfare
Narita Hospital
Chronic thromboembolic pulmonary hypertension(CTEPH) is characterized by persistent pulmonary
arterial obstruction due to organized thrombus
and fibrous tissue. Although balloon pulmonary
angioplasty (BPA) improves hemodynamics andshort-term prognosis in patients with inoperable
chronic thromboembolic pulmonary hypertension(CTEPH), the long-term effects of BPA andprocedure-related complications remain to be
fully elucidated. From July 2009 to October 2016,
we performed a total of 424 BPA sessions in 84
consecutive patients with inoperable CTEPH. We
used 3D reconstructed computed tomography

Page 7

to determine target lesions of pulmonary arteries
and optical computed tomography to selectballoon size, if needed. Before we started BPA
treatment, all patients had been treated withappropriate combination therapy with vasodilators
and warfarin. In 77 patients (92%) who completed
the BPA treatment (65±14 [SD] y.o., male/female
14/63), we examined hemodynamics parameters,
exercise capacity and serum levels of brain
natriuretic peptide (BNP) and compared the data
before first BPA session and those at 6 months after
last BPA session. Moreover, in 53 patients (63%),
we examined the same parameters in the chronicphase (at the time of >12 months after last BPA
sessions. Although medical treatment improved
hemodynamics and exercise capacity, the BPA
treatment significantly and additionally improved
mean pulmonary arterial pressure (38±10 to 25±6mmHg), pulmonary vascular resistance (7.3±3.2
to 3.8±1.0 Wood units) and 6-min walk distance(380±138 to 486±112 meters) (all P<0.01), and theimprovements persisted throughout the follow-up
period (43±27 months) (N=53) . To examine the BPA
procedure-related complications, all 424 sessions
in 84 patients were reviewed. Pulmonary arterial
dissection and hemoptysis were noted in 30 (7%)
and 60 sessions (14%), respectively. Hemoptysis
was noted in 45 sessions during BPA procedures
and in 15 sessions after the procedure. Noneof the patients with PA dissection needed any
additional trans-catheter or surgical proceduresor NPPV. NPPV was used in 33 sessions (8%); 29
for hemoptysis, and 4 for segmental pulmonary
edema. NPPV was used for hemostasis except for
4 cases with segmental pulmonary edema. Only
one patient with hemoptysis subsequently required
oral intubation and mechanical ventilation due
to aspiration pneumonia. In all the remaining
patients, NPPV effectively controlled hemoptysis
and improved pulmonary edema. Furthermore,
5-year survival was 98.4% without peri-procedural
death (only one patient died of colon cancer).
These results indicate that BPA improves
hemodynamics and exercise capacity ininoperable CTEPH patients with acceptablecomplication rate and that the beneficial
hemodynamic effects of BPA persist for years withresultant good long-term prognosis.

International Medical News

International Medical News

LectureⅡ
Percutaneous closure of patent
foramen ovale
Akio Kawamura
Chairman and Professor
Department of Cardiology, School of Medicine
International University of Health and Welfare
Paradoxical embolism is a condition where bloodclot formed in the venous circulation is embolized
to the arterial circulation through right-to-left shunt.
Without right-to-left shunt,blood clot migrating into the heart is captured at
the pulmonary vasculature, the condition called
pulmonary embolism. If the clot is small in size, that
does not cause big clinical problem. However,even tiny thrombus migrating into the arterial
circulation can cause grave organ damage(stroke, myocardial infarction, renal infarction, etc.)
Patent foramen ovale has been on the spotlightas one of the causes of paradoxical embolism.
This anatomical anomaly is also associated withplatypnea-orthodeoxya syndrome (hypoxia
worsened in the upright position), migraine
headache, or diver’s disease.
As a baby grows in the womb, the foramen ovale ispresent in between the right and left top chambersof the heart (atria). It is a vital anatomy for a baby
to deliver oxygen rich blood from mother to thebrain. It normally closes during infancy. When theforamen ovale doesn't close, it's called a patent
foramen ovale. It is estimated that 10-25% ofadults have patent foramen ovale. Interestingly,patent foramen ovale has been found in about50% of patients suffering from stroke without clear
cause (atherosclerosis, atrial fibrillation, etc.). InJapan, paradoxical embolism was found in 5%of acute stroke patients. Every year, more than
200,000 patients develop stroke in Japan, and 5%of them (10,000 patients) seem to be caused byparadoxical embolism.
The diagnosis of paradoxical embolism is madewhen there is a right-to-left shunt, deep venous
thrombosis or pulmonary embolism, imaging
study suggesting arterial embolism without clear
cause of stroke such as atrial fibrillation, infectiveendocarditis, cardiac tumor, and atherosclerosisof aorta or carotid arteries. To detect right-to-leftshunt, cardiac ultrasound with contrast bubble
study is useful. When right-to-left shunt is found,
patent foramen ovale, congenital heart disease,or pulmonary arteriovenous fistula are potential
differential diagnosis.

Page 8The mainstay of treatment of paradoxical embolism
is the secondary prevention. For this purpose,anticoagulants (warfarin and direct thrombin
inhibitors) are the first-line options. Catheter-based
closure of patent foramen ovale has been on thescene for decades, but it has not been approvedin the US or Japan until recently because of lackof strong evidence. In 2017, 3 randomized clinicalstudies were published in the New England Journalof Medicine, and this treatment were given green
light by FDA. A couple years later, it has become
available in Japan as well. When this new option
is considered for patients, however, we need togive some considerations. First, in the 3 randomized
studies, this treatment was shown to be superior to
antiplatelets therapy mostly with aspirin, but it was
not clear whether it is superior to anticoagulation
therapy with warfarin or direct thrombin inhibitors.
Second, the patients included in those studies were
under 60 years old. Elderly are more likely to haveother risk factors of stroke such as atrial fibrillation,
diabetes, and hypertension. For these patients,
patent foramen ovale can be rather a by-standerthan a real culprit. Therefore, at present, it would
be prudent to select this new treatment for young
patients without clear causes of stroke.
For primary prevention of stroke, catheter closureof patent foramen ovale is not recommended.
Indeed, it can play a role in the prevention ofstroke in long airplane travel and divers’ sickness
in individual with patent foramen ovale. These areinteresting topics but awaits future researches.

Page 9International Medical News

Discourse
Introduction of the speaker of discourse
Tsutomu Yamazaki, MD, PhD
Director, IMSJKen Matsui, CEO of ugo, Inc., spoke on The FutureWork Style Opened Up by the Avatar Robot “ugo”.
Mr. Matsui is one of the key businesspeople
representing the millennials. He introduced one
area of applied robot science, which has been
dramatically changing amidst the third robot
boom that began in mid-2010s. Avatar robots are
expected to further evolve through collaboration
with various sensors, AI, facial recognition systems,
etc. (open innovation).

Discourse: The future work style opened
up by the avatar robot “ugo”
Ken Matsui
CEOugo, Inc.
A wide range of services for supporting everyday
life are provided in the cities and towns we live in.
The people who have jobs essential for maintaining
everyday life and activities are called essential
workers.
Meanwhile, when we look at Japan’s labor force
projections, it has been estimated that Japan’slabor force will drop by 14 million people in thenext 20 years. Furthermore, needs for manpower
reduction and remote work/operation have been
rising in almost all sectors in the past few years as
businesses have been forced to continue providing
remote and non-contact services due to the spreadof COVID-19.
In response to those needs, we have developed
the next generation avatar robot “ugo” to serve as
people’s avatar. We provide systems for digitallytransforming tasks by utilizing this robot.
Our problem-solving approach is a robotics
service that enables workers to remotely performtasks from a distant location by placing networkconnected robots at the worksites in facilities. This
enables businesses to assign workers regardless of
their location. Furthermore, tasks can be graduallyautomated based on the data accumulated by
the remote operation of robots.
At present, our systems are utilized mainly inoffice buildings as well as a wide range offacilities including factories, commercial facilities,
condominiums, storage buildings, and nursing
facilities.

We also provide a methodical system called UEOSU
that features robots capable of moving to otherfloors on their own by using elevators. The robots
can either physically manipulate buttons with
their arm to use elevators or use elevators throughcommunication by linking with the building’ssystem. UEOSU expands the range of robot motion,enhancing the benefits of adopting robots.
◆ F ormula for integrating people, robots, and AI:
Worksite tasks DX framework
Instead of handling robots as fixed equipment, wehave been developing systems for engineering work
styles that use robots as tools for expanding humancapabilities. Starting from using systems for remote
operation, businesses can optimize or expand
their scale by outsourcing business processes once
the tasks have been gradually automated andthe accuracy has been established to a certain
degree.
When the automation rate rises gradually, the knowhow of tasks is turned into explicit knowledge andprofitability increases as this knowledge is sharedby the entire organization. To this end, it must be
possible at the worksites to flexibly shift from remote
operation to automation of all basic elements oftasks.
We have developed a system for making this shiftcalled ugo Platform, a web app for easily setting
remote operation and automation of robots on abrowser. Providing the basic functions commonlyrequired by various solutions, ugo Platform serves asa framework for building solutions for a wide rangeof sectors.
◆ Security DX solution utilizing avatar robots
The biggest challenge of the security industry thesedays is the severe shortage of workers. At 6.2, theindustry’s jobs-to-applicants ratio is exceptionallyhigh in comparison to that of other industries. In
response to this situation, we began to provide
a security digital transformation (DX) solution
utilizing ugo robots together with Taisei Co., Ltd.,a comprehensive building maintenance service
provider. The security DX solution materializes
a structure for guards at a building’s disastermanagement center to remotely guard the building
through ugo robots 24 hours a day, 365 days a year;
stand guard duties are remotely performed during
the day and multiple ugo robots patrol each floor
during late-night hours.
◆ T he world brought about by ugo tasks DX
Performing all sorts of tasks, a wide range of robots
already exist in the spaces we live in.

International Medical NewsIn a world where humans and robots work together
cooperatively, there is a need for a setting ofcommon recognition that seamlessly links thephysical world and the digital world to optimize
each other’s activities by mutually recognizing theenvironment where each other’s activities takeplace.
Our avatar robot ugo is optimal for serving the roleof periodically moving and collecting data in thephysical world to build and update the setting ofcommon recognition. Once the wide range ofdata obtained from the physical world can bebuilt and updated in the digital world, the world
where human and robot activities take place canbe visualized, making it easy to obtain new insights
by analyzing the visualized world and conducting
simulations. Tasks and plans to be carried out byhumans and robots can be optimized by feedingback those results to the physical world. The ugotasks DX framework realizes the worksite tasks
optimization cycle by implementing this feedback
loop that links the physical world and the digitalworld.
As these systems expand human capabilities by
seamlessly integrating people, robots, and AI,
businesses utilizing them will be able to realize newwork styles in which workers can perform their tasks
at any time in the day at any location.

Page 10