Combination of Ascending Aortic Replacement and Less Invasive Quick Open Stenting for Distal Aortic Arch Aneurysm with a Penetrating Atherosclerotic Ulcer / 日本心臓血管外科学会雑誌

A 76-year-old man with hypertension had an enlarged distal aortic arch aneurysm with a maximum dimension of 55 mm. Coronary computed tomography angiogram showed none of stenosis in a coronary artery, but penetrating atherosclerotic ulcer at ascending aorta. We performed open surgical repair combination of ascending aortic replacement and less invasive quick open stenting (LIQS) to reduce operative risk, because of his advanced age. The operation was carried out without any complications (Operation time : 242 min, Cardiopulmonary bypass time : 154 min, Aortic cross clamp time : 71 min). The patient's postoperative course was unremarkable, and he was discharged 19 days after surgery. LIQS is effective to reduce operative risk for high-risk patients, and it can be easily combined with other procedures.

Genomic Analysis for Preventing Complications due to Proton Pump Inhibitor and Warfarin Combination Therapy after Open-Heart Surgery / 日本心臓血管外科学会雑誌

<b>Objective</b> : Prevention of gastrointestinal bleeding is imperative in perioperative management of open-heart surgery. Although both proton pump inhibitors (PPIs) and Warfarin are often prescribed to patients following cardiac surgery, the US FDA warns that PPIs increase the international normalized ratio (INR) when used concomitantly with Warfarin, by being metabolized by cytochrome P-450 (CYP) 2C19. We assessed whether this drug interaction depends on the genotype of CYP2C19 (Extensive Metabolizer, EM ; Intermediate Metabolizer, IM ; Poor Metabolizer, PM) or the type of PPI. <b>Methods and Results</b> : In this observational prospective study, the CYP2C9, CYP2C19, and VKORC1 genotypes of 78 patients were analyzed. After excluding cases with ^*1/^*3 of the CYP2C9 genotype and those with C/T of the VKORC1 genotype, 60 patients were assigned to Warfarin+Rabeprazole (RB group, 30 cases) or Warfarin+Lansoprazole (LP group, 30 cases). Warfarin was started with an initial dose of 3 mg, and INR values were measured on days 4, 8, 14, 28, and 56. There was no significant difference in median Warfarin dose between the LP group (2.5 mg/day) and RB group (3.0 mg/day), (<i>p</i>=0.88). The time in the therapeutic range (TTR) (Rosendaal) was significantly higher in the RB group (83.7%) than in the LP group (49.4%), and the time in the over range was significantly higher in the LP group (41.9%) than in the RB group (0.0%). In the LP group, TTR values were higher in CYP2C19 Extensive Metabolizers (EMs) than in Intermediate Metabolizers (IMs) and Poor Metabolizers (PMs), but there was no statistically significant difference between them. Conversely, in the RB group, there was no difference in the values of any CYP2C19 genotype. A multivariate analysis showed that high age and low TTR were risk factors for bleeding. <b>Conclusion</b> : We consider it possible that lower TTR values in the LP group were affected by the CYP2C19 genotype. In an aging society, Rabeprazole is safer and more effective as a proton pump inhibitor after open-heart surgery.