How to do it: endovascular stent and ligament resection during pancreaticoduodenectomy for coeliac axis stenosis in median arcuate ligament syndrome.

To decrease complications associated with the treatment of coeliac axis (CA) stenosis due to median arcuate ligament (MAL) syndrome in pancreaticoduodenectomy, we performed combined preoperative endovascular stenting and intraoperative MAL resection. This technique can secure the CA blood flow to the hepatic artery before surgery in one stage and prevent CA restenosis and stent dislocation because there is no extrinsic compression of the CA after MAL resection.

A mid-ventricular variant of Takotsubo syndrome: was it triggered by insular cortex damage?

Takotsubo syndrome (TTS) is a transient cardiomyopathy that is often associated with cerebrovascular diseases. Earlier studies have supported the concept that the cardiovascular system is regulated by a central autonomic network (CAN) consisting of the insular cortex (IC), anterior cingulate gyrus and amygdala. We report the case of a 79-year-old female diagnosed with a mid-ventricular variant of TTS concomitant with right IC ischaemic stroke. After 12 h of hospitalization, she experienced a sudden collapse. Rapid cardiopulmonary resuscitation resulted in a return of spontaneous circulation. Subsequent left ventriculography revealed akinesis in the mid-portion of the left ventricle with vigorous contraction of the basal and apex segment. Two weeks after admission, cardiac ultrasound showed improved left ventricular contraction. Right IC ischaemia in this patient might have been associated with a dysregulation of the CAN and subsequent increased sympathetic nervous system activity that triggered TTS.

Early drop in systolic blood pressure, heart rate at admission, and their effects on worsening renal function in elderly patients with acute heart failure.

BACKGROUND: Regardless of patients' baseline renal function, worsening renal function (WRF) during hospitalization is associated with poor outcomes. In individuals with acute heart failure (AHF), one predictor of WRF is an early drop in systolic blood pressure (SBP). Few studies have investigated WRF in elderly AHF patients or the influence of these patients' heart rate (HR) at admission on the relationship between an early SBP drop SBP and the AHF. METHODS: We measured the SBP and HR of 245 elderly AHF inpatients (83 ± 6.0 years old, females 51%) at admission and another six times over the next 48 h. We defined 'WRF' as a serum creatinine increase ≥0.3 mg/dL by Day 5 post-admission. We calculated the 'early SBP drop' as the difference between the admission SBP value and the lowest value during the first 48 h of hospitalization. RESULTS: There were significant differences between the 36 patients with WRF and the 209 patients without WRF: early SBP drop (51 vs. 33 mmHg, p < 0.01) and HR at admission (79 vs. 90 bpm, p < 0.05), respectively. In the multiple logistic regression analysis adjusted for the confounders, higher early SBP drop (p < 0.04) and lower HR at admission (p < 0.01) were significantly associated with WRF. No significant association was shown for the interaction term of early SBP drop × HR at admission with WRF. CONCLUSIONS: In these elderly AHF patients, exaggerated early SBP drop and lower HR at admission were significant independent predictors of WRF, and these factors were additively associated with WRF.

Visit-to-visit Blood Pressure Variability and Arterial Stiffness: Which Came First: The Chicken or the Egg?

Earlier studies have shown that visit-to-visit blood pressure (BP) variability (VVV) served as a significant independent risk factor of stroke, specifically, in the high-risk elderly of cardiovascular disease (CVD). Although the mechanism is not clearly understood, arterial remodeling such as carotid artery, coronary artery and large aortic artery would be a strong moderator in the relationship between VVV and CVD incidence. Recent studies have provided evidence that VVV predicted the progression of arterial stiffness. While the class of antihypertensive agents is suggested to be an important determinant of VVV, long-acting calcium channel blockers use (CCBs) is associated with the reduction of VVV, and thus, is suggested to decrease the arterial stiffness. Specifically, the relationship between VVV and coronary arterial remodeling has never been reviewed until now. This article summarizes the recent literature on these topics. In the elderly hypertensives, strict BP control using CCBs could play a pivotal role in suppressing arterial stiffening via VVV reduction.

Predictors of favourable outcome after in-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation: A systematic review and meta-analysis.

AIMS: To identify the predictors of survival to discharge in adults resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR) following in-hospital cardiac arrest (IHCA). METHODS: MEDLINE and ISI Web of Science were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. RESULTS: Eleven studies were included totalling 856 patients. Of these, 324 (37.9%) survived to discharge. Good neurological outcome (Cerebral Performance Category 1 or 2) occurred in 222/263 (84.4%) survivors. Survival was associated with significantly higher odds of an initial shockable rhythm (OR 1.65; 95% confidence interval [95%CI] 1.05-2.61; p=0.03), shorter low-flow time (PMD -17.15 [-20.90, -13.40]min; p<0.00001), lower lactate levels both immediately before ECPR start (PMD -4.12 [-6.0,-2.24]mmol/L; p<0.0001) and on ICU admission (PMD -4.13 [-6.38, -1.88]mmol/L; p<0.0003), lower SOFA score (PMD -1.71 [-2.93, -0.50]; p=0.006) and lower creatinine levels within 24h after ICU admission (PMD -0.37 [-0.54, -0.19]mg/dl; p<0.00001). No significant association was found between survival and age, gender, or cardiac vs. non-cardiac aetiology. The overall QOE was low or very low. CONCLUSIONS: In adult IHCA treated with ECPR a shockable initial rhythm, a lower low-flow time, lower blood lactate levels before ECPR start or on ICU admission, and a lower SOFA score or creatinine levels in the first 24h after ICU admission were associated with a higher likelihood of survival. These factors could help identifying patients who are eligible for ECPR.

Visit-to-Visit Blood Pressure Variability and Alzheimer's Disease: Links and Risks.

While hypertension has been shown to be a risk factor for vascular dementia, several studies have also demonstrated that hypertension also increases the risk of Alzheimer's disease (AD). Although the relationship between visit-to-visit blood pressure variability (VVV) and cognitive impairment, including AD, have been provided, the mechanisms remain poorly understood. This review paper focuses on the relationship of VVV with AD and summarizes the pathophysiology underlying that relationship, which appears to be mediated by arterial stiffness.

The Insular Cortex and Takotsubo Cardiomyopathy.

Transient left ventricular dysfunction in patients under emotional stress, also known as Takotsubo cardiomyopathy, has been recognized as a distinct clinical entity. Recent studies have supported the concept notion that the cardiovascular system is regulated by cortical modulation. A network consisting of the insular cortex (Ic), anterior cingulate gyrus, and amygdala plays a crucial role in the regulation of the central autonomic nervous system in relation to emotional stress such as anxiety, fear and sadness. Because the Ic is located in the region of the middle cerebral arteries, its structure tends to be exposed to a higher risk of cerebrovascular disease. Ic damage has been associated with myocardial injury, increased brain natriuretic peptide, and the incidence of Takotsubo cardiomyopathy. Because Ic damage has been associated with increased sympathetic nervous system activity, Ic damage is suggested to have a pivotal role in the pathophysiology of Takotsubo cardiomyopathy. In this review, we focus on the role of the Ic as a mediator for the cardiovascular system in relation to emotional stress, and we summarizes the current knowledge on the relationships between the Ic and Takotsubo cardiomyopathy.

Intravascular ultrasound for morphological assessment of napkin-ring sign detected on multidetector computed tomography.

BACKGROUND: Although napkin-ring sign (NRS) plaques assessed by multidetector computed tomography (MDCT) is identified as a high-risk feature, the detailed morphological features are still unknown. The purpose of this study was to elucidate the morphological features of the MDCT-assessed NRS using intravascular ultrasound (IVUS). METHODS: We evaluated 204 plaques in 193 patients with non-ST-elevation acute coronary syndrome who were diagnosed using 128-slice MDCT and were assessed using IVUS prior to coronary intervention. Morphology was compared between plaques with and without MDCT-assessed NRS. Severe IVUS-assessed attenuation was defined as an attenuation angle >180°. RESULTS: NRS was detected in 49 lesions. MDCT-assessed plaque attenuation was lower (p<0.0001), and cross-sectional plaque areas at lesion sites, remodeling index, and the prevalence of positive remodeling were greater, in lesions with NRS (p<0.005, p<0.0001, and p<0.0001, respectively). Furthermore, the IVUS-assessed remodeling index and prevalence of severe attenuation and speckled echo appearance were significantly greater in lesions with NRS (p<0.01, p<0.0001, and p<0.0001, respectively). Using multivariate analysis, IVUS-assessed speckled echo appearance was identified as an independent predictor of MDCT-assessed NRS (odds ratio, 3.59; 95% confidence interval, 1.49-8.66; p<0.005). CONCLUSION: MDCT assessment of NRS may be associated with larger heterogeneous necrotic cores and greater positive remodeling.

Visit-to-visit blood pressure variability and classes of antihypertensive agents; associations with artery remodeling and the risk of stroke.

Recent studies have shown that visit-to-visit blood pressure (BP) variability was emerging as an independent risk factor for stroke. Although the mechanism is not fully understood, artery remodeling would be closely associated with the relationship between visit-to-visit BP variability and stroke. In addition, the class of antihypertensive agents is suggested to be an important determinant of visit-to-visit BP variability. This review article summarizes the recent literature on these topics. In the elderly hypertensives, strict BP control using calcium channel blockade would play a crucial role to prevent stroke via reducing the visit-to-visit BP variability.

Usefulness of brain natriuretic peptide for predicting left atrial appendage thrombus in patients with unanticoagulated nonvalvular persistent atrial fibrillation.

BACKGROUND: The CHADS2 scoring system is simple and widely accepted for predicting thromboembolism in patients with nonvalvular atrial fibrillation (NVAF). Although congestive heart failure (CHF) is a component of the CHADS2 score, the definition of CHF remains unclear. We previously reported that the presence of CHF was a strong predictor of left atrial appendage (LAA) thrombus. Therefore, the present study aimed to elucidate the relationship between LAA thrombus and the brain natriuretic peptide (BNP) level in patients with unanticoagulated NVAF. METHODS: The study included 524 consecutive patients with NVAF who had undergone transesophageal echocardiography to detect intracardiac thrombus before cardioversion between January 2006 and December 2008, at Hiroshima City Asa Hospital. The exclusion criteria were as follows: paroxysmal atrial fibrillation, unknown BNP levels, prothrombin time international normalized ratio ≥2.0, and hospitalization for systemic thromboembolism. RESULTS: Receiver operating characteristic analysis yielded optimal plasma BNP cut-off levels of 157.1 pg/mL (area under the curve, 0.91; p<0.01) and 251.2 pg/mL (area under the curve, 0.70; p<0.01) for identifying CHF and detecting LAA thrombus, respectively. Multivariate analyses demonstrated that a BNP level >251.2 pg/mL was an independent predictor of LAA thrombus (odds ratio, 3.51; 95% confidence interval, 1.08-10.7; p=0.046). CONCLUSIONS: In patients with unanticoagulated NVAF, a BNP level >251.2 pg/mL may be helpful for predicting the incidence of LAA thrombus and may be used as a surrogate marker of CHF. The BNP level is clinically useful for the risk stratification of systemic thromboembolism in patients with unanticoagulated NVAF.

Do Lower Target Temperatures or Prolonged Cooling Provide Improved Outcomes for Comatose Survivors of Cardiac Arrest Treated With Hypothermia?

BACKGROUND: Optimal protocols for targeted temperature management are still unclear. This study investigated whether lower target temperatures and/or prolonged cooling could provide improved outcomes in comatose survivors of cardiac arrest. METHODS AND RESULTS: This observational study was conducted using the prospectively collected targeted temperature management database in Hiroshima, Japan. Between September 2003 and September 2014, 237 patients treated with TTM after cardiac arrest were enrolled in this study. The target temperatures and durations were assigned by the treating physicians regardless of the patients' conditions. Favorable outcomes were defined as a cerebral performance category scale of 1 or 2 at the 90-day follow-up time point. The rate of favorable outcomes were similar between the patients whose protocols of target temperature were <34°C and ≥34°C (40% versus 35%, P=0.41), cooling durations were <28 and ≥28 hours (33% versus 44%, P=0.11), and rewarming durations were <28 and ≥28 hours (35% versus 41%, P=0.39). However, in patients treated with extracorporeal cardiopulmonary resuscitation, target temperatures <34°C were associated with more favorable outcomes (29% versus 8%, P=0.01). The cooling and rewarming durations >28 hours and target temperatures <34°C were associated with more frequent lethal arrhythmia, pneumonia, and/or bleedings. CONCLUSIONS: Prolonged durations of cooling and rewarming ≥28 hours may not improve outcomes and may increase complications. Further studies are necessary to assess the hypothesis that target temperatures <34°C provide improved outcomes in patients treated with extracorporeal cardiopulmonary resuscitation.

Association of nonculprit plaque characteristics with transient slow flow phenomenon during percutaneous coronary intervention.

BACKGROUND: The slow flow (SF) phenomenon is more prevalent in patients with acute coronary syndrome (ACS), who frequently exhibit vulnerable plaques in remote coronary arteries. We aimed to clarify the impact of nonculprit plaque characteristics on the occurrence of SF using multidetector computed tomography (MDCT). METHODS: The study population comprised 180 consecutive patients with non-ST-segment elevation ACS (NSTE-ACS) who underwent MDCT before intervention. The characteristics of culprit and nonculprit lesions were compared between patients with and without SF. RESULTS: SF was observed in 43 (23.8%) of the 180 patients. The prevalence of positive remodeling (PR), low-attenuation plaque (LAP), and napkin-ring sign (NRS) in culprit lesion was significantly higher in the SF group than in the non-SF group (86.1% vs. 39.4%; p<0.001, 81.4% vs. 18.3%; p<0.001, and 65.1% vs. 16.1%; p<0.001, respectively). The same result was observed for nonculprit lesions (58.1% vs. 14.6%; p<0.001, 45.2% vs. 6.6%; p<0.001, and 14.3% vs. 4.9%; p<0.04, respectively). Multivariate analysis revealed LAP [odds ratio (OR), 12.8; 95% confidence interval (CI), 3.7-54.7; p<0.001], and NRS (OR, 5.1; 95% CI, 1.3-25.3; p=0.03) in culprit lesions and PR (OR, 4.7; 95% CI, 1.1-22.2; p=0.04) in nonculprit lesions were independently associated with SF. CONCLUSIONS: The plaque characteristics of nonculprit lesions are associated with the occurrence of SF during percutaneous coronary intervention. Assessment of plaque characteristics of both culprit and nonculprit lesions using MDCT may be useful for the prediction of SF.

Percutaneous coronary intervention for postcardiac arrest syndrome.

PURPOSE OF REVIEW: Sudden cardiac arrest is a major cause of unexpected death, as well as a major clinical issue. Primary percutaneous coronary intervention (PCI) can drastically improve outcomes among patients with ST-elevation myocardial infarction without cardiac arrest. Recent studies reported that using emergency PCI to resuscitate patients has the potential to improve their outcomes. The purpose of this review is to elucidate the effects of PCI among resuscitated patients. RECENT FINDINGS: To the best of current understanding, no randomized clinical trial has assessed PCI for postcardiac arrest syndrome. Several observational studies suggested a positive effect of PCI for resuscitated out-of-hospital cardiac arrest (OHCA) patients, and a number of observational studies reported a limited beneficial effect. Several studies reported that a combination of therapeutic hypothermia and PCI may be feasible and effective. However, the presence of bias and unmeasured confounders in these studies may have affected the outcomes. SUMMARY: PCI for postcardiac arrest syndrome may improve outcomes of OHCA patients; however, randomized trials of PCI for postcardiac arrest syndrome are necessary to confirm this issue. Alternative cardiopulmonary resuscitation using venoarterial extracorporeal membrane oxygenation and PCI may have the potential to improve the outcomes of refractory cardiac arrest patients.

Presentations of acute coronary syndrome related to coronary lesion morphologies as assessed by intravascular ultrasound and optical coherence tomography.

BACKGROUND: Pathologically, the lesions responsible for acute coronary syndrome (ACS) are ruptures of vulnerable plaques (and occasionally fibrous-cap erosions or calcified nodules) with a superimposed thrombosis. We aimed to clarify the clinical presentations related to the morphologies of coronary lesions of ACS using intravascular ultrasound (IVUS) and optical coherence tomography (OCT). METHODS AND RESULTS: Seventy-five culprit lesions of ACS patients were clearly assessed with IVUS and OCT. Patients were classified into two groups based on the presence or absence of a rupture of a culprit plaque as identified by OCT. Clinical characteristics and lesion morphologies were compared between the two groups. Waist circumference was significantly greater (p<0.02) and prevalence of the metabolic syndrome (MS) higher (p=0.0011) in the rupture group. The prevalence of prodromal angina was higher in patients without plaque ruptures (p<0.0001). Using multivariate analysis, the MS and prodromal angina were independent predictors of rupture of a culprit coronary plaque (odds ratio (OR): 27.30, p<0.003 and OR: 0.04, p=0.0004, respectively). Among the components of the MS, the prevalence of abdominal obesity was a significant independent predictor of rupture of a culprit plaque (OR: 4.24, p<0.02). CONCLUSIONS: There are two presentations related to the coronary lesion morphologies of ACS: we should understand these aspects of ACS.

Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. METHODS AND RESULTS: This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P=0.01), the intra-arrest PCI was higher (88% versus 70%; P=0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25-51] versus 54 minutes [34-74 minutes]; P=0.002). CONCLUSIONS: Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed.