An Experimental Study of the Effects of IABP on Coronary Artery Bypass Graft Flow Waveform.

PURPOSE: Graft evaluation after coronary artery bypass grafting (CABG) is still not sufficient. This study analyzed the flow waveform of coronary arteries and grafts during intra-aortic balloon pumping (IABP) assist. METHODS: Subjects were eight pigs that underwent off-pump CABG. Using transit-time flow measurement (TTFM) and occluder, blood flow waveforms were recorded while changing the degree of stenosis of Seg.6 and the left internal thoracic artery (LITA) and analyzed by percentage of reverse flow component to the total blood flow (R/T) and the ratio of diastolic blood flow of IABP operative and IABP inoperative (D1/D0). RESULT: Reverse flow of the LITA was reduced when stenosis of Seg.6 increased and R/T decreased. The average diastolic blood flow of Seg.8 and the LITA increased with IABP on showing a D1/D0 of 1 or more. R/T of the LITA increased when stenosis of Seg.6 was fixed and increasing the degree of LITA stenosis. D1/D0 increased up to a 75% LITA stenosis and is decreased in more severe stenosis. CONCLUSION: R/T is significantly higher in the antagonist or stenosis during IABP assist and was able to confirm the effectiveness of the graft as a functional assessment of graft. D1/D0 is useful as an indicator of the effectiveness of IABP on coronary blood flow.

Does Epicardial Adipose Tissue Influence Postoperative Atrial Fibrillation?

PURPOSE: Epicardial adipose tissue (EAT) is associated with atrial fibrillation. We investigated the effect of EAT on postoperative atrial fibrillation (POAF) after cardiac surgery. METHODS: In all, 77 patients underwent scheduled cardiac surgery. Before the operation, we measured total epicardial adipose tissue (Total EAT) and left atrial (LA) EAT by three-dimensional computed tomography (CT). During surgery, we obtained samples of the right atrial appendage, aortic fat, and epicardial fat. The primary endpoint was occurrence of POAF within 1 week after surgery. RESULTS: POAF occurred in 21 patients (27%). Assessment of preoperative characteristics revealed significant differences of age and the use of aldosterone blockers and loop diuretics between the patients with and without POAF. In univariate analysis, the LA EAT/Total EAT ratio, age, use of aldosterone blockers and loop diuretics, P wave duration, cardioplegia volume, and central venous pressure (CVP) were all higher in POAF group. However, logistic regression analysis with propensity score matching found no significant differences of these factors although the LA EAT/Total EAT ratio was higher in POAF group. CONCLUSION: The use of loop diuretics showed the strongest association with POAF. Logistic regression analysis suggested that a high LA EAT/Total EAT ratio had the second strongest association with POAF.

Autotransplantation for Threatened Cardiac Rupture After Left Ventricular Repair.

A 26-year-old Japanese woman experienced threatened cardiac rupture after mitral valve replacement and debridement of a left ventricular (LV) posterior wall abscess caused by infectious endocarditis. We performed cardiac autotransplantation using the bicaval technique to allow bench repair of the recurrent abscess. A balloon catheter was inflated in the inferior vena cava to obtain a bloodless anastomotic field. This is the first report of autotransplantation for threatened LV rupture after posterior wall repair.

Renin-Angiotensin System Control for Chronic Kidney Disease Patients Undergoing Coronary Surgery.

PURPOSE: We investigated the effectiveness of active renin-angiotensin-aldosterone system (RAAS) control with human atrial natriuretic peptide (hANP) and an angiotensin II receptor blocker (ARB) in patients with chronic kidney disease (CKD) undergoing coronary artery bypass grafting (CABG). METHODS: A total of 286 consecutive patients with CKD undergoing CABG were divided into three groups: Group C (n = 50) receiving placebo, the hANP group (n = 60) receiving hANP, and the active RAAS control therapy (ARC) group (n = 56) receiving hANP plus an ARB. Renal function, brain natriuretic peptide (BNP) and RAAS parameters were analyzed. RESULTS: After 1 year, renal function parameters were better in the hANP and ARC groups compared with group C, and the dialysis rate was significantly lower (group C: 12%, hANP group: 1.7%, ARC group: 1.8%, p = 0.018) in the hANP and ARC groups. BNP levels were significantly lower in the hANP and ARC groups compared with group C (p = 0.001). There was also a significant difference of aldosterone among the groups (p = 0.023), as well as a significant difference between group C and the ARC group (p = 0.017). CONCLUSIONS: The present study showed that active RAAS control preserved renal function in patients with CKD undergoing CABG. The improved early postoperative outcome with RAAS control may lead to long-term inhibition of cardiovascular events.

Biventricular repair of pulmonary atresia with intact ventricular septum and severely hypoplastic right ventricle: a case report of a minimum intervention surgical approach.

BACKGROUND: In patients who have pulmonary atresia with an intact ventricular septum and severe right ventricular hypoplasia, biventricular repair is considered to be impossible and multiple interventions are generally required for definitive repair. CASE PRESENTATION: An initial palliative procedure was performed in a 1-month-old boy to promote right ventricular development by pulmonary valvectomy without disrupting the annulus, and appropriate oxygenation was achieved with a central funnel shunt. The retained annulus caused functional stenosis and prevented unfavorable right ventricular dilatation due to regurgitation. Thirteen years later, without any other intervention, reconstruction of the right ventricular outflow tract was successfully performed for definitive biventricular repair by using a new expanded polytetrafluoroethylene bulging valved conduit with extended longevity. CONCLUSIONS: The successful outcome in this case suggests that our minimal palliation strategy could be one option for management of these patients.

New Treatment for Percutaneous Sites in Patients with a Ventricular Assist Device: Nihon University Crystal Violet Method.

BACKGROUND: Infection of the percutaneous site of a ventricular assist device (VAD) is a challenging complication. We report our experience with crystal violet Solbase (Nihon University crystal violet method) for prevention of driveline or cannula infections in VAD patients. PATIENTS AND METHODS: The crystal violet method was used in 10 patients (prophylaxis in nine and treatment in one). Eight patients had an extracorporeal VAD (Nipro) and two had an implantable VAD (Heart Mate II). RESULTS: The infection-free period was 4-623 days (mean: 144.2 ± 222.9 days). All eight patients with an extracorporeal VAD died, while the two patients with an implantable VAD (Heart Mate II) survived. Infection was improved in a patient with MRSA, and the results of bacteriological examination were always negative in the patients receiving prophylaxis. The two patients with an implantable VAD had no infection for 2 and 20 months after implantation. CONCLUSION: These findings suggest that the Nihon University crystal violet method is effective for prevention and treatment of driveline or cannula infections in patients with a VAD.

Changeover Trial of Azilsartan and Olmesartan Comparing Effects on the Renin-Angiotensin-Aldosterone System in Patients with Essential Hypertension after Cardiac Surgery (CHAOS Study).

BACKGROUND: Angiotensin II receptor blockers (ARBs) have been widely used to treat hypertension and large-scale clinical studies have shown various benefits. In this study, we compared olmesartan with azilsartan, the newest ARB. METHODS: The subjects were outpatients who were clinically stable after cardiac surgery. Sixty patients were randomized to receive either azilsartan or olmesartan for 1 year and were switched to the other drug for the following 1 year. The primary endpoints were the levels of plasma renin activity, angiotensin II, and aldosterone. RESULTS: Home blood pressure exceeded 140/90 mmHg and additional antihypertensive medication was administered to 12 patients (20 episodes) in the azilsartan group versus 4 patients (4 episodes) in the olmesartan group, with the number being significantly higher in the azilsartan group. After 1 year of treatment, both angiotensin II and aldosterone levels were significantly lower in the olmesartan group than the azilsartan group. Left ventricular mass index was also significantly lower in the olmesartan group than the azilsartan group. CONCLUSION: This study showed that olmesartan reduces angiotensin II and aldosterone levels more effectively than azilsartan. Accordingly, it may be effective in patients with increased renin-angiotensin-aldosterone system activity after cardiac surgery or patients with severe cardiac hypertrophy.

Efficacy of Carperitide in Hemodialysis Patients Undergoing Cardiac Surgery.

PURPOSE: Recently, performance of cardiac surgery in hemodialysis patients has increased, but the mortality rate is high. METHODS: We retrospectively examined the early and long-term outcomes in 128 dialysis patients who underwent cardiac surgery with or without carperitide infusion and were followed for 2 years. Sixty-three patients received carperitide infusion during surgery and 65 patients did not. RESULTS: The hospital mortality rate was 1.6% in the carperitide group and 12.3% in the non-carperitide group, being significantly lower in the carperitide group. The 2-year actuarial survival rate was 90.5% ± 3.7% in the carperitide group, and 76.9% ± 5.2% in the non-carperitide group, while the major adverse cardiovascular and cerebrovascular events (MACCE)-free rate at 2 years postoperatively was 90.5% ± 3.7% in the carperitide group and 67.7% ± 5.8% in the non-carperitide group. CONCLUSIONS: These findings suggest that carperitide improves the early postoperative outcome in dialysis patients undergoing cardiac surgery, as has already been demonstrated in non-dialysis patients. An early postoperative cardioprotective effect of carperitide and improvement of renal function in oliguric patients might have contributed to this outcome. However, this was a retrospective study, so a prospective investigation is required to demonstrate the mechanisms involved. In addition, further evaluation of the long-term results would be desirable.

Natriuretic peptides for perioperative management of cardiac surgery.

Atrial natriuretic peptide (carperitide) is used to treat heart failure in Japan, while brain natriuretic peptide (nesiritide) is employed in Europe/USA. Patients undergoing cardiac surgery have a complex underlying pathologic state that features increased levels of neurohumoral factors due to activation of the renin-angiotensin-aldosterone system and/or increased sympathetic activity. We considered that perioperative administration of carperitide could be beneficial for cardiac surgery patients, and we have conducted clinical investigations of its use. This article reviews the effects of natriuretic peptides in cardiac surgery patients based on our experience and on previous reports about perioperative management with carperitide or nesiritide.

A new device as an open stent graft for extended aortic repair: a multicentre early experience in Japan.

OBJECTIVES: Open stent grafting for extended aortic repair has been widely carried out around their world. We reported the effectiveness of a new device as an open stent graft for extended aortic repair. METHODS: A new device was used as an open stent graft in this study. The graft part of the device has a woven structure made of Nitinol wire, a superelastic/shape-memory alloy. The subjects of this study were patients aged 20-84 with aneurysms (n = 38) or aortic dissection (n = 22) in the thoracic aorta, including the distal aortic arch and the proximal descending aorta. This study was a multicentre, non-blinded study. The follow-up period was 36 months. RESULTS: Three subjects (5.0%) died during hospitalization due to multiorgan failure. Spinal cord injury (SCI) was observed in 4 subjects (6.7%): paraplegia in 1 and paraparesis in 3 subjects. The 3-year survival rate was 76.7% overall: 68.4% for the subjects diagnosed as having aortic aneurysms (the aortic aneurysm group) and 90.9% for those having aortic dissection (the aortic dissection group). For the aortic aneurysm group, thrombus formation in the aortic aneurysm was observed in 97% of the patients 6 months after operation, and in 100% 12 months after operation. Meanwhile, for the aortic dissection group, with regard to the false lumen of aortic dissection, thrombus formation was observed in 94% of the patients 6 months after operation, in 94% 12 months after operation and in 100% 24 months after operation. Expansion of the aortic aneurysm sac was observed in 2 subjects (6.1%). Among these 2 subjects, endoleak was observed in 1 subject, which was improved by additional thoracic endovascular aortic repair. CONCLUSIONS: The safety and effectiveness of this investigational device was verified over a period up to 36 months after operation. A long-term follow-up would be necessary to further verify the effectiveness of the device in the future.

Cystic Adventitial Disease of the Common Femoral Artery. Case Report and Review of the Literature.

PURPOSE: Cystic adventitial artery disease is an uncommon non-atherosclerotic peripheral vessel disease. Furthermore cystic adventitial disease of the common femoral artery is an extremely rare entity. We report the case of a 54 year-old man complaining of intermittent claudication who was referred to our vascular service. METHODS AND RESULTS: Doppler ultrasound and multidetector-row computed tomography (CT) with 3-dimensional volume rendering revealed severe stenosis with cystic an adventitial cyst in the common femoral artery. Intra-operative Doppler ultrasound showed the cyst to be multilocular type. Reversed great saphenous vein interposition was successfully placed. CONCLUSION: Removal of cyst together with artery and interposition using reversed great saphenous vein is the optimal treatment procedure to prevent recurrence.

New Treatment for Infection of the NIPRO LVAD Cannula Site: Nihon University Crystal Violet Method.

Driveline and cannula site infections are still a frequent adverse event in patients with a ventricular assist device (VAD), and it is important to treat and prevent them because the spread of local infection may cause sepsis in some cases. We report our experience with a patient in whom infection of the NIPRO LVAD cannula site after implantation of an extracorporeal VAD was controlled by treatment with crystal violet Solbase (Nihon University crystal violet method).

Less Invasive Quick Open Stenting using a J Graft Open Stent for Distal Arch Aneurysms.

A new device of aortic stent graft made in Japan has been available since July 2014. Here, we describe a novel, unique surgical technique named "less invasive quick open stenting" at a rectal temperature of 28°C without any cerebral perfusion for treating distal arch aneurysms. All 12 patients were discharged from the intensive care unit within 24 hours after surgery without any complications. This technique aids in the exclusion of atherosclerotic plaques on the aortic wall and shortens the duration of circulatory arrest; moreover, it represents a very attractive option to prevent recurrent nerve injury.

A case of giant saphenous vein graft aneurysm followed serially after coronary artery bypass surgery.

Saphenous vein graft aneurysm (SVGA) is one of the chronic complications after coronary aorta bypass grafting (CABG) and may be caused by atherosclerosis-like phenomena of the vein graft, weakness around the vein valve, rupturing of the suture of the graft anastomosis, or perioperative graft injury. We describe a case of a large, growing saphenous vein graft aneurysm that was followed serially by chest radiography and computed tomography. Eighteen years after CABG, an SVGA (23 × 24 mm) was incidentally detected. The patient was asymptomatic and was followed conservatively. Four years later, coronary computed tomographic angiography showed that the giant aneurysm had grown to 52.1 by 63.8 mm and revealed a second, smaller aneurysm. Finally, the SVG was ultimately resected without bypass via off-pump surgery. Therefore, this case suggested that aggressive treatment that includes surgical intervention should be considered before the aneurysm becomes larger, even if it is asymptomatic.

Safety of The Direct Oral Anticoagulant Edoxaban for Atrial Fibrillation After Cardiac Surgery: Pilot Study.

Direct oral anticoagulants have recently been recommended for non-valvular atrial fibrillation, but have rarely been studied in the field of cardiac surgery. We prospectively investigated the safety of edoxaban, a novel oral anticoagulant, for use in cardiac surgery patients with postoperative atrial fibrillation (POAF), which is the most common complication of cardiac surgery and can lead to stroke. The subjects were adult cardiac surgery patients with POAF who received oral edoxaban for 2 months in an open-label pilot study. The primary endpoint was cerebrovascular/bleeding events up to 2 months, while the secondary endpoints were hemoglobin, prothrombin time, and activated partial thromboplastin time. There were no cerebrovascular or bleeding events during edoxaban treatment and the test drug was not discontinued by any patient. There was no macroscopic hematuria and hemoglobin did not decrease, being significantly higher than the baseline level after 2 months. The prothrombin time was significantly prolonged from 1 week to 2 months and the activated partial thromboplastin time was significantly prolonged from 1 day to 2 months. Echocardiography detected pericardial effusion in 1 patient, but hemoglobin did not decrease and the effusion improved with diuretic therapy. In conclusion, despite the limited sample size of this pilot study, it was demonstrated that edoxaban does not induce bleeding in patients with POAF after cardiac surgery, suggesting that it is safe to perform a large-scale efficacy study of edoxaban as anticoagulant therapy for POAF.

Primary pericardial synovial sarcoma.

A 57-year-old man was admitted to our hospital with cardiomegaly on a chest roentgenogram. A mediastinal tumor was observed during a chest computed tomographic scan and the patient was diagnosed with pericardial synovial sarcoma as a result of a tumor biopsy. Surgery, radiotherapy and chemotherapy were carried out, and although the tumor temporarily decreased in size, it subsequently increased and the patient died approximately 3 years following the initial medical examination. Most synovial sarcomas commonly occur in the vicinity of the joints of the extremities. Therefore, we herein report a rare case of synovial sarcoma which occurred in the pericardium.

Outcomes of Open Surgical Repair for Type B Dissecting Aortic Aneurysm With Alternative Methods in the Endovascular Stent Era.

We assessed the midterm outcomes of 2 types of open surgical repair for type B dissecting aortic aneurysm (BDA). During the last 4 years, 86 patients with BDA (mean age, 68.5 ± 9.8 years; range: 41-87 years) underwent open repair. The average duration between the dissection onset and surgery was 51.5 ± 31.3 months. If the BDA was of open type with patent false lumen or the aneurysm extended for a long segment, descending or thoracoabdominal aortic repair was performed with left thoracotomy. If the BDA was of the closed type with thrombosed false lumen and the aneurysm was located around the distal arch, open stent implantation was performed with our unique technique using circulatory arrest with a rectal temperature of 28 °C without any cerebral perfusion. Left thoracotomy was performed in 68 patients. The durations of aortic clamping and cardiopulmonary bypass were 65.2 ± 16.9 and 78.5 ± 34.6 minutes, respectively. Open stent implantation was performed in 18 patients. The durations of circulatory arrest and cardiopulmonary bypass were 19.1 ± 5.1 and 86.2 ± 17.8 minutes, respectively. In the present study, 4 patients (4.7%) required reexploration for bleeding and 1 patient (1.2%) had a stroke, but none suffered paraplegia. The hospital mortality rate was 1.2% (1 patient), resulting from retrograde type A dissection. The actuarial aortic event-free survival rate, including operative death, was 96.4% at 3 years. Both open surgical procedures for BDA were relatively safe, with favorable early and midterm outcomes, and may be superior for avoiding neurologic complications.

Giant Thrombus Formation Immediately After Mitral Valvuloplasty.

Patients with atrial fibrillation (AF) are at risk of cardioembolism.(1,2)) Atrial thrombus formation associated with AF typically occurs in the left atrial appendage (LAA);(3)) therefore, transesophageal echocardiography (TEE) is important for detection of such a thrombus and measurement of LAA flow velocity.(4,5)) LAA closure is routinely performed during mitral valve surgery in patients with AF to prevent cardiogenic stroke.(6)) We report the case of a 65-year-old woman with severe mitral regurgitation (MR) and AF in whom a giant thrombus formed almost immediately after mitral and tricuspid valvuloplasty and concurrent LAA resection. No atrial thrombus or spontaneous echo contrast (SEC) was detected by TEE before the surgery. However, a giant intramural thrombus was detected in the left atrium 7 days after surgery. It was thought that the atrial dysfunction as well as the change in morphology of the left atrium resulting from the severe MR complicated by AF and congestive heart failure produced a thrombotic substrate. This case suggests that careful surveillance for thrombus formation and careful maintenance of anticoagulation therapy are needed throughout the perioperative period even if no SEC or thrombus is detected before surgery.

Safety and efficacy of landiolol hydrochloride for prevention of atrial fibrillation after cardiac surgery in patients with left ventricular dysfunction: Prevention of Atrial Fibrillation After Cardiac Surgery With Landiolol Hydrochloride for Left Ventricular Dysfunction (PLATON) trial.

OBJECTIVES: We previously conducted a prospective study of landiolol hydrochloride (INN landiolol), an ultrashort-acting ß-blocker, and reported that it could prevent atrial fibrillation after cardiac surgery. This trial was performed to investigate the safety and efficacy of landiolol hydrochloride in patients with left ventricular dysfunction undergoing cardiac surgery. METHODS: Sixty patients with a preoperative left ventricular ejection fraction of less than 35% were randomly assigned to 2 groups before cardiac surgery and then received intravenous infusion with landiolol hydrochloride (landiolol group) or without landiolol (control group). The primary end point was occurrence of atrial fibrillation as much as 1 week postoperatively. The secondary end points were blood pressure, heart rate, intensive care unit and hospital stays, ventilation time, ejection fraction, biomarkers of ischemia, and brain natriuretic peptide. RESULTS: Atrial fibrillation occurred in 3 patients (10%) in the landiolol group versus 12 (40%) in the control group, and its frequency was significantly lower in the landiolol group (P = .002). During the early postoperative period, levels of brain natriuretic peptide and ischemic biomarkers were significantly lower in the landiolol group than the control group. The landiolol group also had a significantly shorter hospital stay (P = .019). Intravenous infusion was not discontinued for hypotension or bradycardia in either group. CONCLUSIONS: Low-dose infusion of landiolol hydrochloride prevented atrial fibrillation after cardiac surgery in patients with cardiac dysfunction and was safe, with no effect on blood pressure. This intravenous ß-blocker seems useful for perioperative management of cardiac surgical patients with left ventricular dysfunction.

Selection of prosthetic valve and evidence--need for the development of Japan's own guidelines.

PURPOSE: In 2014, the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines were largely revised with regard to the selection of prosthetic valves. (1) A mechanical prosthesis is reasonable for aortic valve replacement (AVR) or mitral valve replacement (MVR) in patients less than 60 years of age, (2) A bioprosthesis is reasonable in patients more than 70 years of age, and (3) Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 years of age.Japan faces the unprecedented population aging, and moreover, the average life expectancy is longer among the Japanese than the Westerners. In Japan, whether this choice is appropriate seems questionable. METHODS: This time, with the revision of the AHA/ACC guidelines, it might be necessary to take into consideration the average life expectancy of Japanese people and revise the Japanese guidelines accordingly. RESULTS: We should consider whether 60-70 years should be set as a gray zone regarding the age criteria for choosing biological valves, or if the age should be set higher relative to that specified in the western guidelines, given the longer Japanese life expectancy. CONCLUSION: We believe that the development of unique, Japanese guidelines for the selection of prosthetic valves will allow us to provide appropriate selection and treatment for each patient.