Objective: Neurotrophin-like brain-derived neurotrophic factor (BDNF) and pro-inflammatory cytokines may modulate the pathophysiology of mood disorders. Although several studies show alterations in these biomarkers during the depressive, manic, and euthymic states of mood disorders, evidence is lacking for those in a mixed state. Therefore, this study aimed to investigate the relationship between the depressive mixed state (DMX) and peripheral neurobiological factors. Methods: We enrolled 136 patients with major depressive episodes. Depressive symptoms were assessed using the Quick Inventory of Depressive Symptomatology Self-Report Japanese version (QIDS-SR-J). The severity of DMX was assessed using the self-administered 12-item questionnaire (DMX-12). Categorical screening as DMX-positive (n=54) was determined by a cutoff score of 13 or more in the specific eight symptoms from the DMX-12; the remaining were DMX-negative (n=82). Serum BDNF, tumor necrosis factor-α, highsensitivity C-reactive protein, and interleukin-6 levels were measured. Results: When comparing biomarkers between the DMX-positive and DMX-negative groups, higher serum BDNF concentration in the DMX-positive group than in the DMX-negative group was the only significant finding (p=0.009). A positive correlation existed between the total score of the eight specific symptoms of DMX-12 and the BDNF concentration (r=0.190, p=0.027). After adjustment for confounders, logistic regression analysis revealed that BDNF (odds ratio [OR]=1.07, 95% confidence interval [CI]=1.00–1.14, p=0.045), bipolar diagnosis (OR=3.43, 95% CI=1.36–8.66, p=0.009), and total QIDS-SR-J score (OR=1.29, 95% CI=1.15–1.43, p<0.001) were significantly associated with DMX positivity. Conclusion BDNF was positively associated with DMX severity, suggesting that higher BDNF concentrations may be involved in the pathophysiology of DMX.

An 84-year-old woman, who had undergone ligation for a coronary pulmonary artery fistula, coronary aneurysmectomy, and coronary artery bypass grafting at the age of 76 years, was referred to another hospital for chest pain and diagnosed with acute myocardial infarction based on coronary angiography results. The day after admission, she was transferred to our hospital after her blood pressure decreased and echocardiography showed left ventricular rupture. The Impella CP was introduced on the same day, and the surgery was performed on day 8 after one week of heart failure management. Intraoperative findings revealed a ruptured site in the lateral wall, which was repaired by patch closure. The patient was transferred for rehabilitation on postoperative day 24. As the patient was elderly with multiple organ failure and at high operative risk, a preoperative period to allow remodeling of the infarcted myocardium was considered crucial for a successful repair procedure. The left ventricle was decompressed using the Impella system to prevent enlargement of the rupture site in this case, and a 7-day preoperative optimization period was sufficient for improving myocardial damage. Thus, preoperative Impella-assisted management for left ventricular rupture might be effective in cases of free wall rupture after cardiac surgery with stable hemodynamic status as in the present case or oozing rupture.