Comparison of postoperative exercise capacity of patients who underwent sternal closure with SternaLock Blu and those with traditional sternal wire closure following cardiovascular surgery via sternotomy.

Purpose: This study aimed to evaluate the efficacy of postoperative exercise capacity of SternaLock Blu (Zimmer Biomet, USA) for post-sternotomy patients who underwent cardiovascular surgery. Methods: We investigated 116 patients, including 35 women (mean age 70.3 ± 10.0 years), who underwent cardiovascular surgery by median sternotomy. Patients were candidate for using SternaLock Blu, such as obesity (body mass index > 30/kg/m2), insulin-dependent diabetes mellitus, steroid administrating, undergoing coronary bypass artery grafting used bilateral internal thoracic artery. These patients were categorized into those with SternaLock Blu (S group, n = 47) or with sternal wires only (N group, n = 69) for closing sternotomy, and their data were analyzed. Results: Max Prince Henry Pain Scale (PHPS) was significantly low in the S group than in the N group (N vs. S = 2.7 ± 1.4 vs. 1.6 ± 1.7%, p < 0.001). Postoperative 6-min walk was significantly longer in the S group than in the N group (N vs. S = 346.2 ± 101.6 vs. 408.6 ± 104.6 m, p = 0.018). The length of intensive care unit (N vs. S = 4.9 ± 0.9 vs. 4.0 ± 1.2 days, p < 0.001) and hospitalization (N vs. S = 18.0 ± 5.0 vs. 15.2 ± 3.8 days, p = 0.006) were significantly shorter in the S group than in the N group. Conclusions: SternaLock Blu could keep exercise capacity, and might help reduce postoperative pain and medical treatment period for patients who underwent cardiovascular surgery.

Efficacy of Orexin Receptor Antagonist for Postoperative Atrial Fibrillation in Patients Who Underwent Off-Pump Coronary Artery Bypass Grafting.

PURPOSE: We retrospectively evaluated the postoperative efficacy of an orexin receptor antagonist for patients who underwent off-pump coronary artery bypass grafting (OPCAB). MATERIALS AND METHODS: We invested 108 patients who underwent cardiovascular surgery at our hospital. Patients were categorized as those received orexin receptor antagonist after surgery (S group, n = 64) or without orexin receptor antagonist (N group, n = 44), and the following data were analyzed between both groups. RESULTS: The incidence of postoperative delirium (POD) was significantly less in the S group than in the N group (N vs. S = 36.4 vs. 6.3%, p <0.001). Postoperative new atrial fibrillation (POAF) was significantly less in the S group compared with the N group (N vs. S = 36.4% vs. 12.5%, p = 0.003). Intensive care unit stay (N vs. S = 5.0 ± 1.5 vs. 3.8 ± 0.9 days, p <0.001) and hospitalization (N vs. S = 20.5 ± 9.2 vs. 17.1 ± 7.2 days, p = 0.037) were significantly shorter in the S group compared with the N group. CONCLUSION: Orexin receptor antagonists might reduce POD and POAF, and this effect could introduce the shortness of intensive care unit stay and hospitalization. Orexin receptor antagonist could be useful for patients who undergo OPCAB.

Mid-term results of mitral valve reconstruction with autologous pericardial patch for active infective endocarditis with extensive leaflet destruction.

OBJECTIVES: This study aimed to evaluate the outcomes of our repair technique using autologous pericardial patches for active infective endocarditis with extensive mitral valve destruction. METHODS: From 2009 through 2016, 12 patients with extensive mitral leaflet destruction due to infective endocarditis underwent mitral valve repair with an autologous pericardial patch. Mid-term clinical outcomes and echocardiographic findings of these patients were retrospectively assessed. RESULTS: The perioperative mortality rate was 8.3% (1/12). Postoperatively, the mitral regurgitation grade was ≤ 1 + in all patients. During 5.0 ± 3.2 years of follow-up, there was no recurrence of infective endocarditis or death. There were no cases of mitral regurgitation grade > + 1 and pressure gradient > 5 mmHg during follow-up among 6 patients who underwent posterior leaflet reconstruction, whereas elevation of the pressure gradient was observed in patients who underwent reconstruction of two areas of the anterior leaflet and survived up till the follow-up phase among 3 patients who underwent anterior leaflet repair. The mitral regurgitation grade worsened and pressure gradient was elevated during the follow-up phase in the 2 patients who underwent bi-leaflet repair, and reoperation was performed. CONCLUSION: Mitral valve reconstruction using autologous pericardial patch is a useful treatment option for extensive mitral valve destruction due to active infective endocarditis. Our clinical data revealed that good mid-term results were obtained for posterior leaflet lesions, while extensive anterior leaflet and bi-leaflet lesion repair did not yield satisfactory results. The indication for surgical repair should be carefully evaluated when an extensive anterior region is involved.

Clinical efficacy of digital chest drainage system in cardiac valve surgery.

OBJECTS: The portable digitalized suction was used widely in thoracic surgery. The aim of the study was to access the early outcomes of using the portable digitalized suction system after cardiac surgery. METHODS: We invested 80 patients including 30 women (mean age 72.7 ± 9.2 years) who underwent cardiac surgery at our hospital, excluded coronary artery bypass grafting only, with or only aortic surgery, emergency operation, and patients with hemodialysis. Patients were categorized as those treated with digital chest drainage system (DCS group, n = 38) or analog chest drainage system (ACS group, n = 42), and the following data were analyzed in two groups. The primary endpoint was the duration of chest drainage, and the secondary endpoints were the rate of drainage-related complications and the length of hospitalization. RESULTS: The duration of drainage was significantly shorter in the DCS group (ACS vs. DCS = 94.8 ± 31.5 vs. 81.1 ± 20.6 h, p = 0.036). The duration needed for rehabilitation completion was significantly shorter in the DCS group (ACS vs. DCS = 10.7 ± 1.2 vs. 9.6 ± 1.5 days, p = 0.047), and the length of hospitalization was significantly shorter in the DCS group (ACS vs. DCS = 21.9 ± 5.3 vs. 18.8 ± 7.2 days, p = 0.031). CONCLUSIONS: This study provided evidence that DCS might be effective for patients who underwent cardiac valve surgery.

The back-approach technique of endoscopic saphenous vein harvesting in coronary artery bypass grafting.

PURPOSE: One of the concerns during endoscopic saphenous vein harvesting (EVH) in coronary artery bypass grafting (CABG) is injury to the vein or its branches. The cutting edge of bipolar electrocautery scissors, used to divide the side branches of the saphenous vein, can cause vascular injury leading to reduced graft patency. We have developed a novel back-approach technique using a C-ring to divide the wide side branches of the saphenous vein during EVH. The aim of the study was to describe the technique and assess early outcomes of EVH using this technique. The back-approach technique is as follows: (a) insert the C-ring near the target branch, (b) push the C-ring over the proximal aspect of the target branch, (c) twist the C-ring forward to capture the target branch, and (d) cut the target branch by bipolar electrocautery. METHODS: We investigated 169 patients, including 35 women (mean age 70.1 ± 8.9 years), who underwent CABG at our hospital, using a novel EVH technique. The patients were categorized as those who underwent EVH (EVH group, n = 44) or open vein harvesting (OVH) (OVH group, n = 125). This method involves the creation of a small incision (2 cm), sufficient saphenous vein dissection near the skin incision, adequate dissection to separate the vein from the surrounding tissues, and the back-approach technique with C-ring to divide the side branch of the saphenous vein. The primary endpoint was the graft patency rate, and the secondary endpoints were leg wound complications and length of hospitalization. RESULTS: No significant intergroup difference was observed in early patency of saphenous vein graft patency (OVH vs. EVH = 94.7 vs. 95.6%, p = 0.763). The incidence of lower extremity wound lymphorrhea was significantly lesser (OVH: EVH = 16.0: 0.0%, p = 0.005) and the length of hospitalization was also significantly shorter in the EVH group (OVH vs. EVH = 24.2 ± 9.8 vs. 19.0 ± 5.3 days, p = 0.001). CONCLUSIONS: EVH, using the back-approach technique, showed satisfactory short-term results; therefore, this technique performed with C-ring might be effective for vein harvesting during EVH.

Evaluating the effectiveness of a single CT method for attenuation correction in stress-rest myocardial perfusion imaging with thallium-201 chloride SPECT.

This study aimed to evaluate the effectiveness of a single computed tomography (CT) based attenuation correction method using thallium-201 chloride (201TlCl) in stress-rest myocardial perfusion imaging (MPI). The data of 106 patients who underwent MPI with single photon emission computed tomography (SPECT) using 201TlCl were retrospectively reviewed. MPI SPECT images were reconstructed using stress SPECT and stress CT (SIO), rest SPECT and rest CT (RIO), and rest SPECT and stress CT (RIA). The accuracy of alignment between the SPECT and CT images was evaluated with normalized cross-correlation (NCC) and visual examination. The summed rest score (SRS) was used to evaluate hypoperfusion at rest; washout rate (WO) was used to assess ischemia; and left ventricular ejection fraction (LVEF) was used to evaluate the left ventricle (LV) function. There was no significant difference in NCC and visual evaluation in all three dimensions. The SRS of both RIO and RIA (7.5 ± 7.7 and 7.7 ± 7.6, respectively) did not differ significantly. However, SRSs of RIO and RIA showed a strong correlation (r = 0.98). The WO was 39.0 ± 0.98% for both RIO and RIA, with a strong correlation between the two values (r = 1.00). LVEF was 61.1 ± 17.4% for RIO and 61.3 ± 17.4% for RIA, and a strong correlation was observed between the two values (r = 1.00). In conclusion, the single CT-based attenuation correction method with 201TlCl SPECT has an accuracy equivalent to that of the conventional two CT-based attenuation correction method.

Effectiveness of Endovenous Radiofrequency Ablation for Elderly Patients with Varicose Veins of Lower Extremities.

Objective: The purpose of this study was to evaluate safety and effectiveness of endovenous radiofrequency ablation (RFA) for elderly patients. Materials and Methods: We enrolled 140 patients (194 limbs) who underwent RFA for varicose veins of lower extremities. Patients were divided into two groups; elderly patients (more than 75 years old, E-group, n=36) and young patients (under 75 years old, Y-group, n=104), and perioperative data were analyzed and compared between two groups. Results: In E-group, there were more than patients with hypertension, ischemic heart disease, malignant tumor, and cerebrovascular disease. A partial recanalization was observed in only one limb (0.6%) in Y-group. Endovenous heat induced thrombosis (EHIT) was identified four limbs (2.8%) in Y-group and two limbs (4.1%) in E-group. All EHITs were class 1 by Kabnick classification, and they disappeared within one month after interventions, without antithrombotic therapy. No other major complications were observed. There were no significantly differences for preoperative mean venous clinical severity scores (VCSS) (Y : E=4.84 : 4.47) and postoperative VCSS (Y : E=1.16 : 1.19, 0.35 : 0.58, 0.15 : 0.06, 0.05 : 0.06 at 1, 3, 6, 12 months after) in both groups. Conclusion: RFA for elderly patients is a safe and effective strategy for varicose veins of lower extremities.

Preventive Effect of Suvorexant for Postoperative Delirium after Coronary Artery Bypass Grafting.

OBJECTIVE: Suvorexant is an orexin receptor antagonist and is effective in inducing sleep. We hypothesized that Suvorexant would reduce the incidence of postoperative delirium (POD) after coronary artery bypass grafting (CABG). METHODS: We reviewed 88 patients (12 women, mean age: 69.3 ± 2.5 years) who were undergone CABG alone. Patients were divided into two groups; patients received Suvorexant (S group, n = 36), patients not received Suvorexant (N group, n = 52), and the following data were analyzed and compared between two groups. RESULTS: Intensive Care Unit Delirium Screening Checklist Score was significantly lower in S group compared with N group (N:S = 2.0 ± 1.7:0.8 ± 1.0, p = 0.0003). Although POD was present in 11 of 52 patients (21.2%) in N group, one patient (2.8%) developed in S group (p = 0.008). In S group, both intensive care unit stay (N:S = median 6:5 days, p = 0.001) and hospital stay (N:S = median 23:20 days, p = 0.035) were significantly shorter than in N group. CONCLUSIONS: Suvorexant might reduce incidence of POD in patients undergone CABG.

Usefulness of sternal closure with bioresorbable plate in respiratory function after coronary artery bypass grafting.

OBJECTIVE: The aim of our study is to investigate that sternal reconstruction using bioresorbable plate in median sternotomy may reduce postoperative respiratory dysfunction when compared with wire cerclage only. METHODS: We reviewed 107 patients who were undergone coronary artery bypass grafting with median sternotomy. Patients were divided into two groups; patients underwent sternal reconstruction with bioresorbable plate and wire cerclage (S group, n = 56), patients with wire cerclage only (N group, n = 51), and perioperative respiratory function and postoperative pain score data were analyzed and compared between two groups. RESULTS: There was no significantly difference in preoperative respiratory function in both groups. However, in postoperative change rate of respiratory function, N group had significant decrease compared with S group in vital capacity (VC) (N: S = 74.8 ± 12.4: 85.2 ± 14.8%, p = 0.020), VC as a percentage of predicated VC (N: S = 75.0 ± 12.5: 86.4 ± 15.1%, p = 0.012), and forced expiratory volume in the first second (N: S = 73.7 ± 9.2: 85.3 ± 16.4%, p = 0.012). In Prince Henry Pain Scale, there were significantly more in N group compared with S group (N: S = 3.4 ± 1.0: 2.6 ± 1.4, p = 0.003). CONCLUSION: Sternal fixation with bioresorbable plate could reduce impairment of postoperative respiratory function in comparison to wire cerclage only.

Intervention for Varicose Veins of Lower Extremities Lowers the Brain Natriuretic Peptide Values in Varicose Vein Patients.

Objective: To evaluate the relationship between varicose veins and heart failure, both of which cause edema of lower extremities. Materials and Methods: We enrolled 150 patients who underwent intervention for varicose veins of lower extremities between December 2012 and October 2015, and perioperative data were retrospectively investigated. Results: Of the 150 patients, 104 (69.3%) were females. The mean age was 66.8±10.6 years (27-85 years). Eighty (53.3%) patients had varicose veins in both legs. In all patients, the postoperative (brain natriuretic peptide (BNP) value was significantly lower than the preoperative BNP value (pre : post=39.3 : 30.5 pg/dl, P<0.0001). In patients with higher BNP values (>100 pg/dl), the postoperative BNP values were significantly lower than the preoperative BNP values (pre : post=192.7 : 166.1 pg/dl, P<0.0001). Body weights of the patients decreased differently between pre- and post-operation (pre : post=61.3 : 59.4 kg, P=0.0008). Conclusion: Intervention for varicose veins of lower extremities might be considered clinically useful for the improvement of cardiac function.

Mid-Term Report on the Safety and Effectiveness of Endovenous Radiofrequency Ablation for Varicose Veins.

Objective: Endovenous radiofrequency ablation (RFA), a relatively new technique for treating great saphenous varicose veins, is less invasive compared with stripping surgery. This study examined the mid-term safety and effectiveness of RFA for varicose veins. Materials and Methods: We enrolled 104 patients (147 limbs) who underwent RFA for varicose veins of the lower extremities (females, 67; 64.4%). The mean age was 68.9±9.2 years (39-85 years). In 121 limbs (82.3%), there were great saphenous veins. All patients were observed as outpatients for 12 months after the procedure. RFA was performed using ClosureFast™ catheters with tumescent local anesthesia. Results: There was 99.4% occlusion of the treated veins, and partial recanalization was observed in one limb. Endovenous heat-induced thrombosis (EHIT) was identified in five limbs (3.4%). All EHITs were class 1 according to the Kabnick classification, and they disappeared within 1 month of the intervention without antithrombotic therapy. No other major complications were observed. Mean venous clinical severity scores improved from 5.31 at the baseline to 1.10, 0.39, 0.14, and 0.06 at 1, 3, 6, and 12 months, respectively. Conclusion: RFA is a safe and effective strategy for varicose veins of the lower extremities.

MR Venography for the Assessment of Deep Vein Thrombosis in Lower Extremities with Varicose Veins.

OBJECTIVE: To assess the performance of magnetic resonance venography (MRV) for pelvis and deep vein thrombosis in the lower extremities before surgical interventions for varicose veins. MATERIALS AND METHODS: We enrolled 72 patients who underwent MRV and ultrasonography before stripping for varicose veins of lower extremities. All images of the deep venous systems were evaluated by time-of-flight MRV. RESULTS: Forty-six patients (63.9%) of all were female. Mean age was 65.2 ± 10.2 years (37-81 years). There were forty patients (55.6%) with varicose veins in both legs. Two deep vein thrombosis (2.8%) and three iliac vein thrombosis (4.2%) were diagnosed. All patients without deep vein thrombosis underwent the stripping of saphenous veins, and post-thrombotic change was avoided in all cases. CONCLUSION: MRV, without contrast medium, is considered clinically useful for the lower extremity venous system.

Prevention of atrial fibrillation with ultra-low dose landiolol after off-pump coronary artery bypass grafting.

PURPOSE: Postoperative atrial fibrillation (AF) is a common complication of cardiac surgery that is associated with an increased incidence of other complications. The goal of this prospective randomized study was to evaluate the effect of ultra-low dose landiolol hydrochloride for prevention of AF after off-pump coronary artery bypass grafting (CABG). METHODS: The subjects were 47 patients who underwent isolated CABG and were randomly divided into those who received landiolol from ICU admission until the beginning of oral drug intake (Group L) and those administered diltiazem hydrochloride over the same period (Group D). The incidence of AF within one week after surgery was examined as the primary endpoint. Heart rate, blood pressure, cardiac output, and other hemodynamic parameters were used as secondary endpoints. The rates of adverse events were also recorded. RESULTS: The incidences of AF in the first postoperative week were 4.8% and 27% in Groups L and D, respectively (p = 0.046). There were no differences in hemodynamic parameters between the Groups. In multivariate analysis, no factor emerged as a significant risk factor for postoperative AF. Two patients had adverse events of asthma and hypotension, respectively, in Group L. CONCLUSION: Ultra-low dose landiolol is effective for preventing AF after CABG without worsening hemodynamics.

Long-term results of modified Bentall procedure using flanged composite aortic prosthesis.

PURPOSE: We have been using the flanged composite aortic prosthesis and Carrel button technique to re-attach the coronary ostia in aortic root replacement procedures at our institution over the last twenty five years. Our objective was to evaluate the long-term results of aortic root replacement with this technique. METHODS: A total of 73 patients from January 1984 to August 2010 were included in this study. The median age was 52.7 ± 14.4 years (range 28-80 years). There were 48 male and 25 female patients. 44 patients (60.3%) had annuloaortic ectasia, and 15 patients (20.5%) had acute type A aortic dissection. Marfan syndrome was recognized in 12 patients (16.5%). RESULTS: The early mortality rate was 5.5% (n = 4). Causes of death were multiple organ failures in two patients and sepsis in another two patients. The actuarial survival rate was 84.2% at 5 years, 64.3% at 15 years and 51.9% at 25 years. Only one patient with aortitis needed a reoperation because of coronary pseudoaneurysm after 23 years from the previous operation. CONCLUSION: This modified Bentall procedure is reliable and safe, with superior long-term survival and a low rate of aortic reoperation.

Long-term outcome of active infective endocarditis with renal insufficiency in cardiac surgery.

BACKGROUND: The relation between infective endocarditis (IE) and renal insufficiency is uncertain. The aim of this study was to investigate active IE with renal insufficiency in cardiac surgery. PATIENTS AND METHODS: A retrospective record review was conducted of all cases with IE from January 1998 to July 2009. We identified 38 patients who had undergone surgical intervention (25 males and 13 females, mean age 57.3 ± 15.2 years, range 23-83 years) of IE as defined by the modified Duke criteria. Indications for surgical intervention included new, severe valvular regurgitation with heart failure, intracardiac abscesses, and recurrent embolic events. All patients were divided two groups; one group comprised patients without renal insufficiency (group N, n = 28), the other, those with renal insufficiency (group R, n = 10). RESULTS: Mean age of patients in group R was larger than that in of group N (66.3 ± 10.6 vs. 54.1 ± 15.4 years, p = 0.0268), and mean hemoglobin in group R than in group N (8.4 ± 0.9 vs. 10.3 ± 2.5 g/dl, p = 0.0215). In the early outcome, hospital death was greater in group R than in group N (20.0% vs. 0.0%, p = 0.0143). The 8-year survival was significantly worse in group R than in group N (50.0% vs. 96.4%, log rank test: p = 0.0042). Moreover, the 8-year actuarial freedom from cardiac events was significantly worse in group R than in group N (0.0% vs. 60.3%, log rank test: p = 0.0003), too. Renal insufficiency predicted an increase in long-term mortality (OR 12.104, 95%CI 1.349-108.641, p = 0.0259) and morbidity (OR 10.540, 95%CI 2.173-51.129, p = 0.0035). CONCLUSIONS: In IE, renal insufficiency may allow for risk stratification of patients undergoing surgical intervention.

Pravastatin treatment before coronary artery bypass grafting for reduction of postoperative atrial fibrillation.

PURPOSE: The aim of this observational study was to determine the incidence of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) in patients with or without preoperative pravastatin treatment. METHODS: Between January 2005 and December 2007, a total of 195 patients (39 women, mean age 66.5 +/- 10.2 years) who underwent CABG only were enrolled in this study. Patients were divided into three groups: nonstatin group (n = 111), atorvastatin group (n = 63), pravastatin group (n = 21). The endpoint of the study was the occurrence of new-onset AF during the first 14 days after CABG. RESULTS: Postoperative AF was less frequent in the pravastatin group (9.5%, 2/21 patients) than in the nonstatin group (34.2%, 38/111 patients; P = 0.0025) and the atorvastatin group (34.9%, 22/63 patients; P = 0.0257). C-reactive protein levels were lower in the pravastatin group 72 h after surgery (nonstatin vs. pravastatin, P = 0.0180; atorvastatin vs. pravastatin, P = 0.0383). The Kaplan-Meier analysis showed the protective effect of pravastatin against the risk of developing AF (nonstatin vs. pravastatin, P = 0.0369; atorvastatin vs. pravastatin, P = 0.0378). Multivariable analysis showed that pravastatin treatment conferred a reduced risk of AF (odds ratio 0.22, 95% confidence interval 0.05-0.92, P = 0.0172). CONCLUSION: Pravastatin treatment before CABG may decrease the incidence of postoperative AF.

Clinical characteristics of infective endocarditis with vertebral osteomyelitis.

The relationship between infective endocarditis (IE) and vertebral osteomyelitis (VO) is uncertain. This study investigates the incidence of VO in patients with IE and the outcome of IE-associated VO. Among 58 patients with IE at Musashino Red Cross Hospital from January 2002 to July 2009, 11 patients (19.0%) had VO. Back pain was reported in all cases with VO. Because the antibiotics treatment for VO should continue for 6-8 weeks, hospital stay was significantly longer for patients with VO (75.8 +/- 41.0 days) compared to patients without VO (42.6 +/- 30.4 days; P = 0.0035). Although 6 hospital deaths (15.8%) occurred among the patients without VO, there were no hospital deaths among patients with VO. The 30- and 80-month survival was not significantly different between the patients with VO and without VO (30-month: 88.9% vs 81.7%, 80-month: 88.9% vs 74.3%, respectively). When specifically sought, the incidence of VO is high in patients with IE. VO does not appear to worsen the prognosis of IE, although the need for long hospital stays seems to be more frequent.

New surgical procedure for ischemic/functional mitral regurgitation: mitral complex remodeling.

Although numerous surgical techniques have been developed for ischemic/functional mitral regurgitation, none has clearly improved patient outcome. We report the clinical application of a new mitral complex remodeling procedure for ischemic/functional mitral regurgitation that allows comprehensive remodeling of the entire mitral complex. The mitral complex remodeling procedure consists of three major concepts: division and reconstruction of secondary chords, undersized annuloplasty, and bilateral papillary muscle relocation.