Refractory ventricular arrhythmias during aortic valve replacement and cardiac artery bypass requiring 16 attempts of electrical cardioversion: a case report.

BACKGROUND: We report a patient in whom we failed to suppress ventricular fibrillation (VF) using nifekalant but succeeded using amiodarone during cardiopulmonary bypass (CPB). CASE PRESENTATION: A 65-year-old male with hemodialysis complained of dyspnea and was diagnosed with aortic valve stenosis and angina pectoris; he was opted for elective aortic valve replacement. When the aortic forceps were declamped during CPB, immediate VF was observed; several attempts of electrical cardioversion (EC) with lidocaine and landiolol and three administrations of nifekalant were temporarily effective. However, the rhythm subsequently changed to torsades de pointes. We administered 2 g of magnesium sulfate followed by three doses of amiodarone and initiated continuous infusion. Furthermore, we initiated the pacemaker and intra-aortic balloon pumping. These procedures seemed to be effective; the sinus rhythm was sustained until the end of the surgery. CONCLUSION: We experienced a cardiac surgery requiring 16 EC attempts to terminate the life-threatening arrhythmias using amiodarone.

Usefulness of semiquantitative PCR-Invader assay for selecting candidates for daclatasvir plus asunaprevir combination therapy among patients with hepatitis C virus genotype 1b.

AIMS: PCR-Invader is a highly sensitive assay for detecting non-structural protein 5A (NS5A) resistance-associated variants (RAVs) of hepatitis C virus (HCV). Here, we validated the accuracy of the semiquantitative PCR-Invader (SQ-PI) assay compared to direct sequencing (DS) for identifying NS5A RAVs, and we evaluated the treatment efficacy of daclatasvir plus asunaprevir (DCV + ASV) for patients judged to be non-positive for NS5A RAVs by SQ-PI. METHODS: Detection rates of NS5A RAVs by SQ-PI and DS were compared for 204 patients with HCV genotype 1b. Patients with non-positive results for NS5A RAVs by SQ-PI were treated by DCV + ASV, and the efficacy of this treatment was examined. RESULTS: All samples judged as negative for NS5A RAVs by SQ-PI were similarly judged by DS. However, 29.7% of samples judged as negative for Y93H by DS were judged as weakly positive or positive by SQ-PI. Among 108 patients who were judged as negative by SQ-PI and treated by DCV + ASV, rates of sustained virologic response at 24 weeks (SVR24) were 96.3% in intention-to-treat analysis and 99.0% in patients who completed treatment. Among patients who were weakly positive for Y93H on SQ-PI, the SVR24 rate was 95.0% (19/20). This rate was 100% (78/78) in patients who were negative for Y93H on SQ-PI and completed treatment. CONCLUSION: Treatment efficacy of DCV + ASV was extremely high among patients who were non-positive for NS5A RAVs on SQ-PI, especially for patients with negative results.

Changes in heparin dose response slope during cardiac surgery: possible result in inaccuracy in predicting heparin bolus dose requirement to achieve target ACT.

INTRODUCTION: The substantial interpatient variability in heparin requirement has led to the use of a heparin dose response (HDR) technique. The accuracy of Hepcon-based heparin administration in achieving a target activated clotting time (ACT) using an HDR slope remains controversial. METHODS: We prospectively studied 86 adult patients scheduled for cardiac surgery requiring cardiopulmonary bypass. The total dose of calculated heparin required for patient and pump priming was administered simultaneously to achieve a target ACT of 450 s for HDR on the Hepcon HMS system. Blood samples were obtained after the induction of anesthesia, at 3 min after heparin administration and after the initiation of CPB to measure kaolin ACT, HDR slope, whole-blood heparin concentration based on the HDR slope and anti-Xa heparin concentration, antithrombin and complete blood count. RESULTS: The target ACT of 450 s was not achieved in 68.6% of patients. Compared with patients who achieved the target ACT, those who failed to achieve their target ACT had a significantly higher platelet count at baseline. Correlation between the HDR slope and heparin sensitivity was poor. Projected heparin concentration and anti-Xa heparin concentration are not interchangeable based on the Bland-Altman analysis. CONCLUSION: It can be hypothesized that the wide discrepancy in HDR slope versus heparin sensitivity may be explained by an inaccurate prediction of the plasma heparin level and/or the change in HDR of individual patients, depending on in vivo factors such as extravascular sequestration of heparin, decreased intrinsic antithrombin activity level and platelet count and/or activity.

Management of a Patient With Antiphospholipid Syndrome Undergoing Aortic Valve Replacement Using the Hepcon Hemostasis Management System Plus and Rotational Thromboelastometry: A Case Report.

A 72-year-old woman with antiphospholipid syndrome underwent aortic valve replacement. Her preoperative activated partial thromboplastin time was 61.7 seconds and activated clotting time was 219 seconds. During cardiopulmonary bypass, the Hepcon Hemostasis Management System (HMS) Plus determined the heparin dose needed to maintain whole-body heparin at 3 U/mL. After cardiopulmonary bypass, 100 mg of protamine was administered based on heparin-protamine neutralization, and the activated clotting time decreased. We applied rotational thromboelastometry (ROTEM) to diagnose residual heparin using the INTEM/HEPTEM clotting time ratio. The HMS and ROTEM are useful for heparin-protamine control in antiphospholipid syndrome.

Laparoscopic caudal approach for a small hepatocellular carcinoma located in the paracaval portion of a cirrhotic liver.

Resection of a tumor located in the paracaval portion of the liver, without sacrificing other parts of the liver, is surgically challenging. Here, we describe using a laparoscopic caudal approach for a small hepatocellular carcinoma located in the paracaval portion. It is the first case using the laparoscopic caudal approach to be reported in the literature. Compared with the conventional approaches, this procedure can minimize both surgical invasiveness and the volume of liver parenchyma to be resected. In addition, the laparoscopic view is suitable for this procedure. The laparoscopic caudal approach can be a safe procedure with minimal invasiveness for a small paracaval tumor, particularly in patients with liver cirrhosis.

Risk factors for deterioration of long-term liver function after radiofrequency ablation therapy.

AIM: To identify factors that influence long-term liver function following radiofrequency ablation (RFA) in patients with viral hepatitis-related hepatocellular carcinoma. METHODS: A total of 123 patients with hepatitis B virus- or hepatitis C virus-related hepatocellular car-cinoma (HCC) (n = 12 and n = 111, respectively) were enrolled. Cumulative rates of worsening Child-Pugh (CP) scores (defined as a 2-point increase) were examined. RESULTS: CP score worsening was confirmed in 22 patients over a mean follow-up period of 43.8 ± 26.3 mo. Multivariate analysis identified CP class, platelet count, and aspartate aminotransferase levels as signi-ficant predictors of a worsening CP score (P = 0.000, P = 0.011 and P = 0.024, respectively). In contrast, repeated RFA was not identified as a risk factor for liver function deterioration. CONCLUSION: Long-term liver function following RFA was dependent on liver functional reserve, the degree of fibrosis present, and the activity of the hepatitis condition for this cohort. Therefore, in order to maintain liver function for an extended period following RFA, suppression of viral hepatitis activity is important even after the treatment of HCC.

The incidence and risk factors for the development of hepatocellular carcinoma after peginterferon plus ribavirin therapy for chronic hepatitis C.

BACKGROUND/AIMS: Although the incidence of hepatocellular carcinoma (HCC) has been shown to be reduced after pegylated glycol-interferon plus ribavirin (Peg-IFN/RBV) therapy in patients with chronic hepatitis C, the risk factors for the development of HCC are not fully understood. The aim of this study was to clarify the incidence and the risk factors for the development of HCC after Peg-IFN/RBV therapy in patients with chronic hepatitis C. METHODOLOGY: A total of 474 patients with chronic hepatitis C who received Peg-IFN/RBV therapy between December 2004 and August 2010 were enrolled and followed in a multicenter trial. The patients were assessed for HCC by either ultrasound or computed tomography every 6 months. The incidence and risk factors for the development of HCC were identified. RESULTS: Of the 474 patients, 23 developed HCC during a median follow-up of 4 years and 8 months (range 1-6 years and 3 months) after completion of Peg-IFN/RBV therapy. According to a univariate analysis, higher age, low platelet counts, a low level of serum albumin, a high level of alpha-fetoprotein (AFP) and a sustained viral response (SVR) to Peg-IFN/RBV therapy were independent factors associated with the occurrence of HCC. The multivariate analysis using the Cox proportional hazard model revealed the risk factors for HCC were the platelet count, AFP level and the outcome of Peg-IFN/RBV therapy. CONCLUSIONS: To reduce the incidence of HCC in chronic hepatitis C, attainment of a sustained response rate is an essential issue. For patients with low platelet counts and/or a high AFP level, strict surveillance should be continued even after eradication of HCV because the risk of HCC was found to be higher for these patients.

Beneficial effects of dietary fish-oil-derived monounsaturated fatty acids on metabolic syndrome risk factors and insulin resistance in mice.

The aim of this study was to elucidate the effect of fish-oil-derived monounsaturated fatty acids (MUFAs) containing large amounts of C20:1 and C22:1 isomers on metabolic disorders in mice. Male C57BL/6J mice were fed a 32% lard diet (control) or a 27% lard plus 5% saury-oil-derived MUFA diet for 6 weeks. Dietary MUFA improved insulin resistance and alleviated metabolic syndrome risk factors by reducing blood glucose and lipids. These favorable changes may be attributed to an improved adipocytokine profile. MUFA ingestion resulted in favorable changes in mRNA expression of genes involved in glucose/lipid metabolism (SCD-1, CPT1a, UCPs, and CS) as well as inflammation (MAC1, MMP3, and SAA3) and alterations in fatty acid composition. Our data suggest that marine MUFA improved glucose/lipid homeostasis and hindered the development of metabolic syndrome in obese mice.

Knowledge of Vibrio vulnificus infection among Japanese patients with liver diseases: a prospective multicenter study.

BACKGROUND: Vibrio vulnificus (V. vulnificus) is a seafood-borne infectious pathogen that can be lethal to humans. The infection has been correlated with pre-existing liver disease, particularly liver cirrhosis. Awareness of V. vulnificus infection among Japanese citizens is low, despite the increasing number of patients with hepatocellular carcinoma (HCC). The present study was conducted to assess the level of knowledge of patients with liver disease regarding V. vulnificus infection. MATERIAL/METHODS: Questionnaires were sent to patients with chronic liver disease who had been treated by liver specialists at 14 medical institutes. RESULTS: Of 1,336 patients, 304 (22.8%) had liver cirrhosis, and 732 (54.8%) had comorbidities of this disease. Only 14.5% (194/1,336) of patients had knowledge of V. vulnificus infection. Of 304 patients with liver cirrhosis, 17.4% (53/304) of the patients had knowledge of V. vulnificus infection. Of 60 patients with liver cirrhosis and diabetes mellitus, 11 (18.3%) patients had knowledge of V. vulnificus infections. Even when the patients with high risk factors such as liver cirrhosis and diabetes mellitus had knowledge of V. vulnificus infections, most ate raw seafood without regard to season. CONCLUSIONS: Patients with chronic liver diseases and their physicians need to be better educated about V. vulnificus infection and its prevention.

Selenium deficiency in a patient with Crohn's disease receiving long-term total parenteral nutrition.

We report a case of selenium deficiency in a patient with Crohn's disease on long-term total parenteral nutrition (TPN). She manifested lassitude of the legs, discoloration of the nail beds, and macrocytosis. Since her plasma selenium level was found to be below the measurable level, we diagnosed this case as selenium deficiency. After intravenous administration of sodium selenite, her symptoms were reversed. Careful attention should be paid to selenium deficiency when a patient receives long-term TPN; supplementary administration of selenium via TPN may be required because selenium is often not routinely added to TPN formulations.