Novel clipping procedure for preventing post-operative inguinal hernia in robot-assisted radical prostatectomy.

OBJECTIVES: Inguinal hernia (IH) is a common postoperative complication after robot-assisted radical prostatectomy (RARP). We developed a novel clipping technique for the prevention of IH developing after RARP. METHODS: This cohort included 759 consecutive patients who underwent RARP for prostate cancer at the University of Tokyo Hospital between January 2011 and December 2018. We reviewed clinical parameters and identified the risk factors of postoperative IH. The prophylactic preventive procedure of IH development was performed by clipping the peritoneum and underlying tissue around the internal inguinal ring using Hem-o-Lok clip to prevent the prolapse of the intestine through the internal inguinal ring. RESULTS: In total, 236 patients received the clipping procedure. The median follow-up time was 50 months. The incidence rate of IH was 10.8% (78/720). The median time to the diagnosis of IH was 10 months. Univariate analysis revealed that patients with higher age (age ≥ 63), low BMI (BMI < 25 kg/m2), and lower number of surgical experiences (Surgical experience < 40) showed a significantly higher odds ratio of developing IH. Multivariate analysis showed that "BMI < 25 kg/m2" and "Surgical experience < 40" were independent predictive factors of IH. Among the patients with a high risk of IH due to receiving surgery from inexperienced surgeons, there was a statistically significant preventive effect for the patients with "BMI ≥ 25 kg/m2" by the novel clipping procedure. CONCLUSIONS: The novel clipping procedure reduced the risk of post-operative IH in obese patients when the RARP was performed by inexperienced surgeons.

Helix-fixation leadless pacemaker as a potential alternative to conventional transvenous pacemaker in post-Mustard baffle stenosis.

Obstruction of a systemic venous pathway is relatively common after the Mustard operation. A helix-fixation leadless pacemaker was successfully implanted in the subpulmonic but morphologic LV in a d-TGA patient with post-Mustard baffle stenosis and failure of a previously implanted epicardial lead.

Behavior of the OptiVol2 fluid index and intrathoracic impedance on remote monitoring As a detector of subclinical device infection early after implantation.

We report the behavior of OptiVol2 fluid index (OVFI2) and intrathoracic impedance on remote monitoring before the appearance of signs of infection. A sustained rise in OVFI2 early after implantation reflects peri-device fluid retention.

Preoperative Prediction of Shock Impedance for Subcutaneous Implantable Cardioverter Defibrillator Using Chest Computed Tomography.

BACKGROUND: High shock impedance is associated with conversion failure among patients with subcutaneous implantable cardioverter defibrillators (S-ICD). Currently, there is no preoperative assessment method for predicting high shock impedance. This study examined the efficacy of chest computed tomography (CT) as a preoperative evaluation tool to assess the shock impedance of S-ICDs. METHODS AND RESULTS: The amount of adipose tissue adjacent to the device and anteroposterior diameter at the basal heart region were measured preoperatively using chest CT. We examined the correlation between these measurements and shock impedance at the conversion test. We enrolled 43 patients with S-ICDs (mean [±SD] age 54±15 years; body mass index 23±4 kg/m2; PRAETORIAN score 30-270 points; amount of adipose tissue 1,250±716 cm3), who underwent intraoperative conversion tests by inducing ventricular fibrillation, which was terminated with a 65-J shock. A sufficient concordance correlation coefficient was observed between the shock impedance and the amount of adipose tissue (r=0.616, P<0.01) and anteroposterior diameter (r=0.645, P<0.01). In multiple regression analysis, the amount of adipose tissue (ß=0.439, P=0.009) and anteroposterior diameter (ß=0.344, P=0.038) were identified as independent predictive factors of shock impedance. CONCLUSIONS: The preoperative CT-measured amount of adipose tissue and basal heart anteroposterior diameter are independent predictors of shock impedance. These parameters may be more accurate in identifying higher shock impedance in patients with S-ICDs.

Protist dynamics in the eastern Tsugaru Strait, Japan from 2010 to 2018: Implications for the relationship between decadal climatology and aquaculture production.

Environmental changes such as seasonality, decadal oscillation, and anthropogenic forcing may shape the dynamics of lower trophic-level organisms. In this study, 9-years (2010-2018) of monitoring data on microscopic protists such as diatoms and dinoflagellates, and environmental variables were analyzed to clarify the relationships between plankton and local/synoptic environmental changes. We found that time-series temperature increased in May, whereas it decreased in August and November. Nutrients (e.g., phosphate) decreased in May, remained unchanged in August, and increased in November from 2010 to 2018. The partial pressure of CO2 increased in May, August, and November over time. It is notable that the change in seawater temperature (-0.54 to 0.32 °C per year) and CO2 levels (3.6-5.7 µatm CO2 per year) in the latest decade in the eastern Tsugaru Strait were highly dynamic than the projected anthropogenic climate change. Protist abundance generally increased or stayed unchanged during the examined period. In August and November, when cooling and decreases in pH occurred, diatoms such as Chaetoceros subgenus Hyalochaete spp. and Rhizosoleniaceae temporally increased from 2010 to 2018. During the study period, we found that locally aquacultured scallops elevated soft tissue mass relative to the total weight as diatom abundance increased, and the relative scallop soft tissue mass was positively related to the Pacific Decadal Oscillation index. These results indicate that decadal climatic forcing in the ocean modifies the local physical and chemical environment, which strongly affects phytoplankton dynamics rather than the effect of anthropogenic climate change in the eastern Tsugaru Strait.

Successful Epicardial Radiofrequency Ablation of Ventricular Tachycardia That Shared a Pathway with Bi-Directional Conduction in a Patient with Human Immunodeficiency Virus-Associated Cardiomyopathy.

A 59-year-old man who had been diagnosed with human immunodeficiency virus-associated cardiomyopathy was referred for catheter ablation of ventricular tachycardia (VT). An electrocardiogram (ECG) waveform revealed that the clinical VT originated from the epicardium. A deceleration zone (DZ) was identified on an isochronal late activation map. Moreover, 2 forms of monomorphic VT were induced by different cycle length burst pacings from near the DZ. The morphologies of the 2 VTs with an identical cycle length were very likely to use a shared common pathway with bi-directional conduction around the slow conduction area in the left ventricle posterolateral small epicardial surface area. After ablation of the DZ, the VT was uninducible.

Revisiting predictors of worse atrioventricular valve and left ventricular systolic function following pacemaker therapy.

BACKGROUND: Predictors of worsening atrioventricular valve regurgitation and left ventricular (LV) systolic function after implantation of a leadless pacemaker (LPM) remain unclear compared with those of a transvenous pacemaker (TPM). METHODS: We retrospectively analyzed 205 patients who were newly implanted with a permanent pacemaker (119 LPMs and 86 TPMs) and underwent transthoracic echocardiography before and 8 ± 5 months after implantation. We evaluated the worsening of tricuspid and mitral regurgitation (TR and MR), defined as at least one-grade aggravation in severity, and changes in LV ejection fraction (LVEF). RESULTS: Worsening TR occurred more frequently in the LPM group compared to the TPM group (33% vs. 20%, p = .04); however, there was no significant difference between the two groups regarding worsening MR (26% vs. 18%, p = .18) and LVEF change (-2 ± 10% vs. -3 ± 8%, p = .40). In multivariable analysis, independent predictors for worsening TR, MR, and LVEF after implantation were found to be (1) the change from sinus rhythm at baseline to atrioventricular asynchronous right ventricular (RV) pacing (odds ratio [OR]: 5.68, 95% confidence interval [CI]: 1.94-16.70, p < .01); (2) the change from non-pacing ventricular contraction at baseline to RV pacing (OR: 2.42, 95% CI: 1.12-5.24, p = .02); and (3) a higher RV pacing burden (ß: -0.05, 95% CI: -0.08--0.02, p < .01), respectively. CONCLUSION: Worsening TR, MR, and LVEF after pacemaker implantation were not associated with the type of pacing device but loss of atrioventricular synchrony or dependency on RV pacing.

Two-year Outcomes of Ventricular-demand Leadless Pacemaker Therapy for Heart Block After Transcatheter Aortic Valve Replacement.

Ventricular-demand leadless pacemakers (VVI-LPMs) have often been used as an alternative to atrioventricular (AV) synchronous transvenous pacemakers (DDD-TPMs) in patients with high-grade AV block following transcatheter aortic valve replacement (TAVR). However, the clinical outcomes of this unusual usage are not elucidated. Patients who received permanent pacemakers (PPMs) owing to new-onset high-grade AV block after TAVR from September 2017 to August 2020 at a high-volume center in Japan were included in the analysis, and the clinical courses of VVI-LPM and DDD-TPM implants through 2 years of follow-up were compared retrospectively. Out of 413 consecutive patients who underwent TAVR, 51 (12%) patients received a PPM. After excluding 8 patients with chronic atrial fibrillation (AF), 3 with sick sinus syndrome, and 1 with incomplete data, 17 VVI-LPMs and 22 DDD-TPMs were included in our final cohort. The VVI-LPM group had lower serum albumin levels (3.2 ± 0.5 vs. 3.9 ± 0.4 g/dL, P < .01) than the DDD-TPM group. Follow-up revealed no significant differences between the 2 groups in terms of the incidence of late device-related adverse events (0% vs. 5%, log-rank P = .38) and new-onset AF (6% vs. 9%, log-rank P = .75); however, there were increases in the rates of all-cause death (41% vs. 5%, log-rank P < .01) and heart failure rehospitalization (24% vs. 0%, log-rank P = .01) in the VVI-LPM group. This small retrospective study reveals favorable post-procedural complication rates but higher all-cause mortality with VVI-LPM compared to DDD-TPM therapy for high-grade AV block after TAVR at 2 years of follow-up.

Multicenter Study of Surgical Ablation for Atrial Fibrillation in Aortic Valve Replacement.

There is controversy regarding appropriate surgical ablation procedures concomitant with nonmitral valve surgery. We retrospectively investigated the impact of surgical ablation for atrial fibrillation during aortic valve replacement between 2010 and 2015 in 16 institutions registered through the Japanese Society for Arrhythmia Surgery. Clinical data of 171 patients with paroxysmal and nonparoxysmal atrial fibrillation undergoing aortic valve replacement were collected and classified into full maze operation (n = 79), pulmonary vein isolation (PVI) (n = 56), and no surgical ablation (n = 36) groups. All patients were followed up and electrocardiograms were recorded in 68% at 2 years. The myocardial ischemia time was significantly longer in the maze group than the others during isolated aortic valve replacement (p ≤ 0.01), but there were no significant differences in 30-day or 2-year mortality rates between groups. The ratios of sinus rhythm at 2 years in paroxysmal and nonparoxysmal atrial fibrillation in the maze group versus PVI group were 87% versus 97%, respectively (p = 0.24) and 53% versus 42%, respectively (p = 0.47). No patients with nonparoxysmal atrial fibrillation in the no surgical ablation group maintained sinus rhythm at 2 years. In conclusion, both maze and PVI during aortic valve replacement are valuable strategies to restore sinus rhythm at 2 years and result in favorable early and midterm survival rates.

Paralytic Ileus during Treatment of Pulmonary and Renal Tuberculosis in a Non-Human Immunodeficiency Virus Patient: An Unusual Presentation of Tuberculosis-immune Reconstitution Inflammatory Syndrome.

Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.

Comparison of hemodynamics and root configurations between remodeling and reimplantation methods for valve-sparing aortic root replacement: a pulsatile flow study.

PURPOSE: To compare the characteristics of reimplantation (RI) using grafts with sinuses and remodeling (RM) with/without external suture annuloplasty using a pulsatile flow simulator. METHODS: Porcine aortic roots were obtained from an abattoir, and six models of RM and RI with sinuses were prepared. External suture annuloplasty (ESA) was performed in the RM models to decrease the root diameter to 22 mm (RM-AP22) and 18 mm (RM-AP18). Valve models were tested at mean pulsatile flow and aortic pressure of 5.0 L/min and 120/80 (100) mmHg, respectively, at 70 beats/min. The forward flow, regurgitation, leakage, backflow rates, valve-closing time, and mean and peak pressure gradient (p-PG) were evaluated. Root configurations were examined using micro-computed tomography (micro-CT). RESULTS: The backflow rate was larger in the RM models than in the RI models (RI: 8.56% ± 0.38% vs. RM: 12.64% ± 0.79%; p < 0.01). The RM-AP and RI models were comparable in terms of the forward flow, regurgitation, backflow rates, p-PG, and valve-closing time. The analysis using a micro-CT showed a larger dilatation of the sinus of the Valsalva in the RM groups than in the RI group (Valsalva: RI, 26.55 ± 0.40 mm vs. RM-AP22, 31.22 ± 0.55 mm [p < 0.05]; RM-AP18, 31.05 ± 0.85 mm [p < 0.05]). CONCLUSIONS: RM with ESA and RI with neo-sinuses showed comparable hemodynamics. ESA to RM reduced regurgitation.

Report of Accidental Anchoring of an Impella Device to a Perceval Bioprosthesis in a Patient.

We herein report a case in which we encountered complications when placing an Impella CP ventricular assist device (catheter-based ventricular assist device) in a patient with a Perceval bioprosthetic valve (sutureless valve). Specifically, the catheter-based ventricular assist device became anchored to the sutureless valve and needed to be removed under cardiopulmonary bypass. (Level of Difficulty: Advanced.).

Age distribution of Antarctic Bottom Water off Cape Darnley, East Antarctica, estimated using chlorofluorocarbon and sulfur hexafluoride.

Chlorofluorocarbon (CFC) and sulfur hexafluoride (SF6) were used to investigate the timescale of Antarctic Bottom Water (AABW) that spreads off Cape Darnley (CD) in East Antarctica. The age of the AABW was estimated based on the observed SF6/CFC-12 ratio while taking into account tracer dilution by Lower Circumpolar Deep Water. Along the western canyons off CD and the ~ 3000 to 3500 m isobaths, the bottom water age was < 5 years, reflecting the spread of newly formed CD Bottom Water. Higher ages of ~ 8 years obtained for areas east of CD and > 20 years in the northwestern offshore region indicate inflows of AABW through the Princess Elizabeth Trough and Weddell Sea Deep Water, respectively. This study determined the age distribution in the region off CD, where three different types of AABW spread.

Clinical Utility and Characteristics of the LARS Score Compared to the CCIS.

PURPOSE: The low anterior resection syndrome (LARS) score (LS) has been widely validated and has become an international tool for evaluating postoperative bowel dysfunction. However, many physicians still use the conventional incontinence scores in LARS treatment. Moreover, interpretation of LS and its relationship with conventional incontinence scores are not yet well understood. Here we compared the LS with the Cleveland Clinic Incontinence Score (CCIS) to clarify the clinical utility and characteristics of the LARS score. METHODS: We performed a multicentre observational study, recruiting 246 rectal cancer patients following sphincter-preserving surgery. Patients completed the LS, CCIS, and SF36 questionnaires. RESULTS: The response rate was 76.4%, and a total of 180 patients were analysed. The LS was strongly correlated with the CCIS (P < 0.001, rs = 0.727). However, among 116 patients determined to not have incontinence (CCIS 0-5), 51 (44%) were diagnosed with LARS (29 with minor LARS and 22 with major LARS). Among 68 patients without LARS, only 3 were diagnosed as having incontinence (CCIS > 6). In comparison with background factors, aging and elapsed time were associated with only LS. High LS and CCIS both showed significant quality-of-life impairment as assessed by the SF-36. CONCLUSION: This is the first study to determine the difference in the numeric values between the CCIS and LS. The LS can be a convenient tool for LARS screening, identifying a wide range of patients with LARS, including those with incontinence evaluated by CCIS. Assessment using the CCIS may often underestimate LARS.

Clinical Outcomes of Non-Atrial Fibrillation Bradyarrhythmias Treated With a Ventricular Demand Leadless Pacemaker Compared With an Atrioventricular Synchronous Transvenous Pacemaker　- A Propensity Score-Matched Analysis.

BACKGROUND: Implanting a ventricular demand leadless pacemaker (VVI-LPM) for patients with non-atrial fibrillation (AF) bradyarrhythmias such as sick sinus syndrome (SSS) or high-grade (i.e., second- or third-degree) atrioventricular (AV) block is not recommended unless they have limited vascular access or a high infection risk; nevertheless, an unexpectedly high number of VVI-LPM implantations have been performed. This study investigated the clinical outcomes of these unusual uses.Methods and Results:This study retrospectively analyzed 193 patients who were newly implanted with a VVI-LPM or an atrioventricular synchronous transvenous pacemaker (DDD-TPM) for non-AF bradyarrhythmias at a high-volume center in Japan from September 2017 to September 2020. Propensity score-matching produced 2 comparable cohorts treated with a VVI-LPM or DDD-TPM (n=58 each). Each group had 20 (34%) patients with SSS and 38 (66%) patients with high-grade AV block. During a median follow up of 733 (interquartile range 395-997) days, there were no significant differences between the VVI-LPM and DDD-TPM groups regarding late device-related adverse events (0% vs. 4%, log-rank P=0.155), but the VVI-LPM group had a significantly increased readmission rate for heart failure (HF) (29% vs. 2%, log-rank P=0.001) and a tendency to have higher all-cause mortality (28% vs. 4%, log-rank P=0.059). CONCLUSIONS: The implantation of a VVI-LPM for non-AF bradyarrhythmias increased the incidence of HF-related rehospitalization at the mid-term follow up compared to the use of a DDD-TPM.

Higher serum alkaline phosphatase value indicates the need for bone mineral density testing in non-metastatic prostate cancer patients undergoing androgen deprivation therapy.

PURPOSE: Osteoporosis is a well-known adverse effect of androgen deprivation therapy for prostate cancer. This study aimed to reveal the factors associated with the diagnosis of osteoporosis in prostate cancer patients undergoing androgen deprivation therapy. METHODS: This retrospective cross-sectional study included 106 prostate cancer patients treated with androgen deprivation therapy. Patients with bone metastasis at the initiation of androgen deprivation therapy and those with castration-resistant prostate cancer were excluded. Bone mineral density was measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry. Osteoporosis was defined as bone mineral density equal to or below either -2.5 SD or 70% of the mean in young adults. The association between clinicopathological variables and bone mineral density or diagnosis of osteoporosis was investigated. RESULTS: Thirty-six (34%) patients were found to have osteoporosis. The incidence of osteoporosis increased in a stepwise manner depending on the duration of androgen deprivation therapy. Multivariate logistic regression analysis identified a longer duration of androgen deprivation therapy (months, odd's ratio = 1.017, P = 0.006), lower body mass index (kg/m2, odd's ratio = 0.801, P = 0.005) and higher serum alkaline phosphatase value (U/l, odd's ratio 1.007, P = 0.014) as the factors independently associated with the diagnosis of osteoporosis. Eleven out of 50 (22%), 14 out of 35 (40%) and 11 out of 20 patients (55%) were osteoporotic in the patients with serum alkaline phosphatase values <238 U/l, 238-322 U/l and >322 U/l, respectively (P = 0.022). CONCLUSIONS: Osteoporosis is common in prostate cancer patients undergoing androgen deprivation therapy; furthermore, its incidence increases depending on the duration of androgen deprivation therapy. Bone mineral density testing should be considered for all patients on androgen deprivation therapy, especially for those with a lower body mass index and higher serum alkaline phosphatase value.

Pannus-related left main trunk ostial stenosis after aortic valve replacement.

A 34-year-old woman was hospitalized with shortness of breath and chest tightness and pain. She had undergone aortic valve replacement for aortic stenosis at the age of 18 years. Transthoracic echocardiography showed left ventricular asynergy and a high aortic valve pressure gradient. Thus, structural valve deterioration was diagnosed. Coronary computed tomography and coronary angiography revealed left main trunk ostial stenosis that had caused acute anteroseptal myocardial infarction. Urgent surgery revealed pannus formation around the prosthetic valve and covering the ostium of the left main trunk. A Bentall procedure and coronary artery bypass grafting were performed. The postoperative course was uneventful.

Revisit to the Prognostic Value of Premature Atrial Contraction Burden in 24-h Holter Electrocardiography for Predicting Undiagnosed Atrial Fibrillation　- A Propensity Score-Matched Study.

BACKGROUND: The optimum cut-off value of premature atrial contraction (PAC) burden (CV-PACb) in 24-h Holter electrocardiography (24-h ECG) for predicting atrial fibrillation (AF) is debatable, with few validation data.Methods and Results:We retrospectively analyzed 61 patients already diagnosed with AF (AD-AF) and 147 patients never diagnosed with AF (ND-AF), aged ≥50 years, free of heart disease, and who had undergone 24-h ECG and transthoracic echocardiography (TTE). Receiver operating characteristic analysis demonstrated that 0.4% was the optimal CV-PACb differentiating AD-AF from ND-AF, with 69% sensitivity and 72% specificity (area under the curve [AUC] 0.72; 95% confidence interval [CI] 0.65-0.79); however, the left atrial volume index was not significant (AUC 0.60; 95% CI 0.51-0.68). To verify the CV-PACb, new propensity-matched cohorts (i.e., subjects with a PAC burden ≥0.4% and <0.4%; n=69 in each group) were compared based on new detection of AF at a median follow-up of 50 months (interquartile range 12-60 months) Multivariable Cox regression analysis revealed that among 24-h ECG and TTE findings, only PAC burden ≥0.4% was independently associated with incident AF (hazard ratio 5.28; 95% CI 1.28-26.11; P=0.023). CONCLUSIONS: A high PAC burden (≥0.4%) in 24-h ECG was a reliable indicator to identify undiagnosed AF, whereas TTE parameters did not show any predictive value.