Lowered postoperative ldl-c/hdl-C ratio reduces later cardiovascular events after abdominal aortic aneurysm surgery.

PURPOSE: To examine the relationship between the incidence of later cardiovascular events after abdominal aortic aneurysm (AAA) surgery and postoperative lipid levels. METHODS: Atherosclerotic risk factors including postoperative serum lipid levels were examined in 116 patients aged 70 or less undergoing an elective AAA surgery. Later cardiovascular events after AAA surgery occurred in 21 patients, including cerebral infarction (n = 4), catheter intervention or surgery for coronary artery disease (CAD) (n = 10) and other vascular disease. RESULTS: Postoperative cholesterol levels during the average follow-up period of 55.6 ± 44.3 (months) were 49.0 ± 15.7 (mg/dL) for high-density lipoprotein cholesterol (HDL-C), 97.9 ± 31.2 (mg/dL) for low-density lipoprotein cholesterol (LDL-C), which were both significantly improved compared to preoperative values (p <0.001). Cox hazard analysis indicated that preexistent CAD significantly increased in the risk for later cardiovascular events (hazard ratio 5.67; 95%CI 1.92-16.8; p = 0.002) and lowered postoperative LDL-C/HDL-C ratio <1.5 decreased in the risk after AAA surgery (hazard ratio 0.10; 95%CI 0.01-0.83; p = 0.033). Patients with postoperative LDL-C/HDL-C ratio <1.5 (n = 22) had a significantly better cardiovascular event-free rate than those with that ratio ≥1.5 (n = 94) (p = 0.014). CONCLUSION: Lowered postoperative LDL-C/HDL-C ratio <1.5 can decrease in the risk for later cardiovascular events after AAA surgery. These results may support the rationale for postoperative aggressive lipid-modifying therapy.

Lowered LDL-C Levels Reduce Later Local Vascular Events after Surgical or Endovascular Treatment of Peripheral Artery Disease.

PURPOSE: To examine the relationship between incidence of later, local vascular events (restenosis and occlusion) and clinical factors including lipid levels after surgical or endovascular treatment of peripheral artery disease (PAD). METHODS: Consecutive 418 PAD lesions (in 308 patients under the age of 70) treated with surgical (n = 188) or endovascular (n = 230) repair for iliac (n = 228) and infrainguinal (n = 190) lesions were retrospectively analyzed. Clinical features and lipid levels were compared between patients who developed vascular events (n = 51; VE group) and those who did not (n = 257; NoVE group). RESULTS: Among assessed factors, post-therapeutic low-density lipoprotein cholesterol (LDL-C) levels (mg/dL) were significantly higher in the VE group (120.4 ± 31.2) than in the NoVE group (108.2 ± 25.1) (P = 0.01). Infrainguinal lesions were more common in the VE than in the NoVE group (P <0.001). Cox hazard analysis indicated that infrainguinal lesions relative to iliac lesions significantly increased the risk of vascular events (hazard ratio (HR) 3.35; 95% CI 1.63-6.90; P = 0.001) and post-therapeutic LDL-C levels <130 (mg/dL) decreased the risk (HR 0.34; 95%CI 0.17-0.67; P = 0.002). CONCLUSION: Lowered post-therapeutic LDL-C levels can decrease the risk of later, local vascular events after PAD treatment. These results may support the rationale for aggressive lipid-modifying therapy for PAD.

Preoperative HDL-C Predicts Later Cardiovascular Events after Abdominal Aortic Aneurysm Surgery.

PURPOSE: To determine the predictive value of serum lipid levels on the development of later cardiovascular events after abdominal aortic aneurysm (AAA) surgery. METHODS: A total of 101 patients under 70 undergoing an elective AAA surgery were divided into the following two groups: 1) those who developed later cardiovascular events after AAA surgery, including cerebral infarction (n = 4), catheter intervention (PCI) or surgery for coronary artery disease (CAD) (n = 9) and other vascular disease. (CVE group; n = 19); 2) those without later events (NoCVE group: n = 82). Preoperative atherosclerotic risk factors including serum lipid levels were subjected to univariate and multivariate analysis. RESULTS: The CVE group showed a significantly lower high-density lipoprotein cholesterol (HDL-C) level (32.9 ± 6.6 vs 41.6 ± 12.1 mg/dL; p <0.001), higher low-density lipoprotein cholesterol (LDL-C) / HDL-C ratio (4.30 ± 1.01 vs 3.24 ± 1.15; p = 0.001), and higher prevalence of mild CAD (without an indication of PCI) (p = 0.029) preoperatively. Cox hazard analysis indicated that preexistent mild CAD (hazard ratio 4.70) and preoperative HDL-C <35 mg/dL (hazard ratio 3.07) were significant predictors for later cardiovascular events after AAA surgery. CONCLUSION: Patients at high risk for later cardiovascular events should require a careful follow-up and may also require an aggressive lipid-modifying therapy.

Maximum aortic diameter as a simple predictor of acute type B aortic dissection.

OBJECTIVES: To identify the most prognostic predictor of Stanford type B aortic dissection at admission. PATIENTS AND METHODS: Forty-three patients with Stanford type B aortic dissection were divided into two groups: (1) those who developed dissection-related events later (EV group: n = 18), including the need for surgery (n = 12), rupture (n = 1), dissection-related death (n = 5), and aortic enlargement > or =5 mm in diameter per year (n = 15); (2) those without later events (NoEV group: n = 25). Clinical features, aortic diameters, and blood flow status were compared. RESULTS: The maximum aortic diameter at admission was 41.5 +/- 1.7 mm for the EV group, which was significantly greater than the NoEV group (34.4 +/- 0.9 mm, p <0.001). A maximum aortic diameter > or =40 mm was found in 11 patients (61%) of the EV group, whereas this maximum was found in 4 (16%) of the NoEV group (p = 0.004). A patent false lumen at admission was found in all patients of the EV group and in 17 (68%) of the NoEV group (p = 0.013). Other factors were not significant. A Cox hazard analysis indicated a maximum aortic diameter > or =40 mm as a significant predictor for dissection-related events (hazard ratio 3.13, p = 0.032). The presence of a patent false lumen did not reach a statistical significance. CONCLUSION: Our results indicated that a maximum aortic diameter > or =40 mm at admission was the most prognostic factor for developing late dissection-related events, rather than the presence of a patent false lumen.

Septal myectomy, papillary muscle resection, and mitral valve replacement for hypertrophic obstructive cardiomyopathy: a case report.

We report a case of hypertrophic obstructive cardiomyopathy (HOCM) successfully treated with septal myectomy and mitral valve replacement (MVR) combined with a resection of the hypertrophic papillary muscles. The patient, a 74-year-old woman, first underwent the conventional septal myectomy through aortotomy. The papillary muscles revealed a marked hypertrophy, but extended myectomy and precise resection of the hypertrophic papillary muscles were thought to be difficult through the aortotomy. Through the right-sided left atriotomy, MVR and resection of the papillary muscles were additionally performed. The patient was smoothly weaned from the cardiopulmonary bypass, and the postoperative course was uneventful. The outflow pressure gradient was relieved to 0 mm Hg, from 94. The mean pulmonary artery pressure was reduced to 27 mm Hg, from 42. The patient has been doing well in the New York Heart Association (NYHA) functional class between I and II during 45 months of follow-up, without complications related to the use of a prosthetic valve. Septal myectomy is the procedure of choice in the surgical treatment of HOCM for most cases, but some may require additional mitral valve procedures. In patients with marked hypertrophic papillary muscles, MVR and resection of the muscles may be an option of treatment to ensure a relief of the outflow obstruction and to abolish systolic anterior movement in units with limited experience.

Idiopathic retroperitoneal fibrosis in a patient suspected of impending rupture of the abdominal aortic aneurysm.

Retroperitoneal fibrosis (RPF) is a relatively rare disease which shows a periaortic mass in the retroperitoneal area and predisposes to an obstructive uropathy. We report a case of idiopathic RPF occurring in a patient who was suspected of impending rupture of abdominal aortic aneurysm. A 60-year-old male, with a 2-week history of abdominal pain, was transferred for evaluation of the periaortic mass. Computed tomographic (CT) scan revealed radiological findings such as leakage of contrast media from the aortic lumen and expansion of the periaortic mass. The patient underwent laparotomy, which revealed retroperitoneal fibrotic plaques in the absence of aortic aneurysm. The pathological findings of the biopsy specimen were consistent with idiopathic RPF. The patient received ureteral stent placement and was treated with steroid therapy. When a similar case is encountered, our recommendations are as follows: (i) Both CT scan and magnetic resonance (MR) imaging should be performed to determine whether the retroperitoneal mass is due to idiopathic or secondary RPF. If idiopathic RPF is suspected, the patient should receive primary steroid therapy. (ii) Retroperitoneal periaortic mass indicates a need for the assessment of obstructive uropathy. Early placement of the ureteral stent is necessary for urinary decompression and preservation of the renal function in patients with obstructive uropathy.

Pulmonary thromboembolectomy in congenital antithrombin III deficiency associated with acute pulmonary embolism -report of a case-.

Antithrombin III (AT III) deficiency is a rare hereditary disease that predisposes to thromboembolic complications. We report a case of AT III deficiency complicated with acute pulmonary thromboembolism, successfully treated with emergency pulmonary thromboembolectomy after insertion of an inferior vena cava filter. AT III activity before treatment was found to be 44% of normal value and remained less than 50% of normal throughout the postoperative course. In his family line, both the patient's aunt and deceased father had a history of pulmonary infarction. AT III activity of the patient's aunt was 47 to 58% of normal value. The patient was discharged on the 15th day after surgery and has been doing well for four years receiving warfarin as anticoagulant therapy. Careful follow-up is essential for early detection of the recurrent pulmonary thromboembolism resulting in pulmonary hypertension and/or right heart failure.

Emergency surgical treatment for acute occlusion of the left main coronary artery-report of a case-.

We report a case of acute occlusion of the left main coronary artery (LMCA) successfully treated with percutaneous transluminal coronary angioplasty (PTCA) under the use of percutaneous cardiopulmonary bypass support (PCPS) and subsequent coronary artery bypass grafting (CABG). CABG was started only two hours after admission, and subsequent reperfusion of left anterior descending artery (LAD) after completing distal and proximal anastomosis was achieved 60 minutes later. Although postoperative CK levels were elevated to 10,900 IU/l, akinesis of the left ventricular (LV) wall was limited to segment #1 and #2, and hypokinesis in segment #3 and #6 documented by postoperative left ventriculogram (LVG). The patient was discharged from the hospital on foot without neurologic sequelae and is doing well and in New York Heart Association (NYHA) functional class I in 20 months of follow-up. Simultaneous efforts to maintain systemic circulation and to achieve reperfusion of the occluded LMCA as soon as possible are essential for survival. Prompt introduction of mechanical circulatory support and early revascularization to minimize the infarct area are both necessary.

Coronary artery bypass surgery in patients with abdominal aortic aneurysm: detection and treatment of concomitant coronary artery disease.

OBJECTIVES: Complication due to coronary artery disease (CAD) is a major cause of mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The purpose was to show 1) the incidence of patients who required coronary artery bypass grafting (CABG), and 2) risk factors for the necessity of CABG in patients with AAA. METHODS: Subjects were consecutive 159 patients (132 males and 27 females) undergoing elective repair of non-ruptured AAA between May 1993 and March 2002. Most patients (n=145) underwent routine preoperative coronary angiography (CAG) and received coronary revascularization when necessary. Clinical atherosclerotic risk factors were subjected to univariate and multivariate analysis to determine predictors for the necessity of CABG. RESULTS: Of 43 patients (27.0%) with significant coronary stenosis, 7 patients (4.4%) underwent CABG concomitantly (n=1) or prior to the AAA repair (n=6) in the same admission. Other patients received percutaneous transluminal coronary angioplasty (PTCA) (n=14) and isolated medical treatment (n=22). Overall mortality of 159 patients undergoing AAA repair was 2.5% and there were no deaths in 7 patients undergoing CABG. Univariate and multivariate analysis indicated only the history of angina as significant for the necessity of CABG in patients with AAA. Of 155 survivors, 5 patients underwent CABG later in the follow-up period. CONCLUSIONS: The incidence of patients who required CABG in the treatment of AAA was 4.4% in our institute. It was difficult to predict the necessity of CABG without conducting CAG in patients with asymptomatic myocardial ischemia. These results may justify the routine enforcement of preoperative CAG in patients with AAA.