A Clinical Association between an Increasing Renal Resistive Index and the Atherosclerotic Burden in Patients with a Preserved Renal Function.

Objective A positive correlation is observed between the progression of renal impairment and the increasing risk of cardiovascular disease. Our aim was to examine the relationship between the renal resistive index (RRI) assessed by duplex sonography and the extent of atherosclerosis in patients without renal impairment undergoing vascular imaging studies. Methods The RRI was evaluated pre-procedurally among 106 outpatients with an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 undergoing clinically-driven coronary computed tomography angiography (CCTA). In those subjects, a carotid artery ultrasound scan was also performed to evaluate carotid artery disease. We investigated the association between the RRI and the atherosclerotic extent, defined by the presence of coronary artery calcium (CAC) >0 and carotid intima-media thickness (cIMT) ≥1.0 mm. Results Multi-site atherosclerosis (CAC>0 and cIMT≥1.0 mm) was found in 31 patients. The RRI was significantly increased with an increasing number of atherosclerotic vessels (absence of atherosclerosis: 0.65±0.04 vs. single-site atherosclerosis: 0.67±0.06 vs. multi-site atherosclerosis: 0.71±0.05, p<0.001). A multivariate logistic regression analysis showed that RRI>0.70 [odds ratio (OR): 4.05, 95% confidence interval (CI), 1.37-12.0, p=0.01], cardio ankle vascular index (CAVI) ≥9.0 (OR: 8.18, 95% CI: 2.47-27.1, p<0.01), diabetes (OR: 4.34, 95% CI: 1.37-13.7, p=0.01) and an eGFR>90 mL/min/1.73 m2 (OR: 5.89, 95% CI: 1.39-25.1, p=0.01) were associated with multi-site atherosclerosis. Conclusion The RRI, a sub-clinical renal parameter is an atherosclerotic marker in patients without renal impairment.

The prognostic impact of the controlling nutritional status (CONUT) score in patients undergoing cardiovascular surgery.

BACKGROUND: Various postoperative predictive markers following cardiovascular surgery have been examined for use in the current aging population. The controlling nutritional status (CONUT) score, which is advocated not only as a screening tool for poor nutritional status, but also as an immunonutritional assessment, has started to attract attention in several clinical settings, such as in cancer and heart failure patients. The aim of this study was to evaluate the value of the CONUT score as a postoperative prognostic marker in patients who underwent cardiovascular surgery. METHODS: A total of 75 patients who underwent elective cardiovascular surgery between January 2015 and October 2017 were retrospectively analyzed. The patients were divided into two groups according to their preoperative CONUT score (i.e., CONUT < 2 or CONUT ≥ 2), and their clinicopathological characteristics, surgical outcomes, and overall survival were compared. The median follow-up period was 23 months (range 0-43 months) after surgery. RESULTS: The high CONUT group (CONUT ≥ 2), which consisted of 30 (40.0%) patients, had a significantly worse prognosis than the low CONUT group with regard to overall survival (p = 0.0007). On multivariate analyses, the CONUT score was identified as the only independent prognostic factor for overall survival (hazard ratio 1.47 per 1 CONUT score increase, 95% confidence interval 1.05-2.06, p < 0.026). CONCLUSIONS: The CONUT score is a reliable and independent preoperative predictor of overall survival after cardiovascular surgery.

Endovascular Treatment for Kommerell's Diverticulum with a Right-Sided Aortic Arch.

We report a rare case of type A dissection involving a right-sided aortic arch with an aberrant left subclavian artery originating from Kommerell's diverticulum in a 76-year-old woman. Endovascular treatment for Kommerell's diverticulum including intimal tear of the dissection was performed. At the 5-year follow-up, the patient was doing well, with no endoleak or dilatation of the Kommerell's diverticulum.

Addition of a renin-angiotensin-aldosterone system inhibitor to a calcium channel blocker ameliorates arterial stiffness.

BACKGROUND: The aim of controlling hypertension is to protect against arteriosclerosis. Calcium channel blockers (CCBs) and renin-angiotensin-aldosterone system (RAAS) inhibitors have been reported to have antihypertensive effects, but their effect on the progression of arteriosclerosis is not fully understood. The cardio-ankle vascular index (CAVI) was developed to estimate arterial stiffness, which reflects arteriosclerosis. In this study, we investigated the longer term effects of CCBs and RAAS inhibitors on the progression of arteriosclerosis by monitoring the CAVI. METHODS: Our subjects were 115 consecutive, non-smoking hypertensive patients on oral treatment with a CCB and/or RAAS inhibitor for at least 3 years in whom the CAVI was measured on two occasions approximately 1 year apart during the period from January 2009 to December 2011. Changes in CAVI were evaluated in patients administered a CCB alone (group C), an RAAS inhibitor (group R) alone, or both drugs together (group B). Changes in laboratory findings, blood pressure, and ankle-brachial index were similarly evaluated. RESULTS: No significant change in laboratory findings, blood pressure, or ankle-brachial index was noted in any of the groups. The CAVI decreased slightly in group R (first recording 8.80±1.03, second recording 8.57±0.97, P=0.517) and increased significantly in group C (first 8.45±0.92, second 8.95±1.04, P=0.038), but showed no significant change in group B (first 9.01±1.26, second 9.05±1.35, P=0.851). CONCLUSION: Long-term administration of a CCB alone increased the CAVI, but this effect was offset by the concomitant use of a RAAS inhibitor, indicating that a RAAS inhibitor might protect against arteriosclerosis.

A Case of an Aortic Abscess around the Elephant Trunk.

A 52-year-old male patient with a history of total arch replacement using the elephant trunk technique for acute aortic dissection 4 years before visited our hospital with the chief complaint of persistent fever. Chest computed tomography (CT) suggested prosthetic vascular graft infection, which was treated surgically after chemotherapy. The first surgery consisted of debridement of an abscess around the vascular graft and in the aorta around the elephant trunk, and thoracic descending aorta replacement and vacuum-assisted closure (VAC) in view of the risk of bleeding from the peripheral region of the elephant trunk. One week later, omental filling was performed as the second step. This is a very rare case of aortic abscess around the elephant trunk that could successfully be managed by graft-conserving treatment.

[Surgical Repair of Coarctation of the Aorta in an Adult;Report of a Case].

We present a case of 30-year-old man with successful bypass grafting for coarctation of the aorta. Hypertension was identified during a health examination. Blood pressure difference between the upper and lower limbs was about 60 mmHg. Computed tomography( CT) revealed stenosis of the distal aortic arch and development of collateral arteries. The pressure gradient across the coarctation by catheterization was 56 mmHg. After left thoracotomy through the 4th intercostal space, a bypass graft using a 14-mm woven Dacron graft was placed between the left subclavian artery and descending aorta without the use of extracorporeal circulation. Postoperative course was satisfactory, with minimal pressure difference between the upper and lower extremities. The patient was discharged 16 days postoperatively. As of 7 years later, he remains asymptomatic, and CT has revealed no marked changes of the aorta or bypass graft.

Morphological Evaluation of Proximal Anastomosis by PAS-Port(®) System in Patients with Long-Term Patent Grafts.

PURPOSE: We examined grafts employing for morphological analysis of early and long-term results on proximal anastomosis with the PAS-Port(®). METHODS: One hundred and four patients treated by OPCAB with PAS-Port(®) were performed postoperative MDCT. Morphological evaluation of the proximal anastomotic region was classified into three groups (A; graft was anastomosed almost perpendicularly to the aortic wall, B; graft was same type A, but subsequently curved to form an acute angle with the aortic wall, C; graft take off acute angle with the aortic wall) evaluated on planar and sagittal sections. RESULTS: One hundred twenty-six PAS-Port(®) were used. Patency rate was 99.0% at discharge, 94.7% at 1 year, and no blockages were detected thereafter in patients examined. The morphology rate was A 50.6%, B 15.3% and C 34.1% on planar sections, and A 58.8%, B 10.6% and C 30.6% on sagittal sections. CONCLUSION: The morphological evaluation of grafts revealed the degree of freedom in graft design to be relatively high and long-term patency posed no particular problem even if the layout of the proximal anastomotic region involved a relatively acute angle. The PAS-Port(®) was considered to be a highly reliable device which performed appropriate proximal anastomosis and improved the patency of vein grafting to the aortic wall.

Usefulness of perioperative blood glucose control in patients undergoing off-pump coronary artery bypass grafting.

OBJECTIVE: We investigated the usefulness of perioperative blood glucose control in patients undergoing coronary artery bypass grafting (CABG). METHODS: DM patients were aggressively treated with intensive insulin therapy to achieve a preoperative fasting blood glucose level of 140 mg/dl and a postoperative level of 200 mg/dl. For comparison, patients were divided as follows: (1) DM group vs. non-DM group, and (2) for mean blood glucose level in the intensive care unit (ICU), lower than 200 mg/dl (IL) vs. 200 mg/dl or higher (IH). RESULTS: (1) In the DM group, the amount of insulin (U) used during surgery was greater (P<0.05), and the duration of ICU stay was longer (P<0.05). The incidence of all complications was higher in the DM group (P<0.05). (2) Between the IH group (54) and the IL group (82), the proportion of DM patients was higher in the IH group (75% vs. 38%, P<0.05). In the IH, the duration of ICU stay (P<0.01) was longer, and the incidence of all complications was higher (P<0.05). (3) In the DM group, the incidence of complications tended to be higher in the IH group. The incidence of complications was extremely low in the non-DM group. CONCLUSION: Strict perioperative blood glucose control may help to improve the outcomes of CABG.

Evaluation of bioprosthetic valve for small aortic root in elderly patients.

The hemodynamics of stentless bioprostheses are superior to those of mechanical valves, especially for patients with a small aortic root. Between March 1999 and July 2001, we implanted 18 Freestyle stentless porcine valves using our technique of repeated division of the space by halving the distance. Seven patients received 19-21-mm valves and 11 received 23-25-mm valves. Clinical data and early and midterm outcomes of both groups were compared. The mean preoperative echocardiography gradient of the small valve group was 84.7 mm Hg, and when discharged from hospital, the mean gradient was 14.8 mm Hg. One operative death was encountered due to arrhythmia. This stentless porcine prosthesis has excellent hemodynamics and can be implanted safely and easily, even in elderly patients with a small aortic root, using our suture technique.

Assessment of on-pump beating coronary artery bypass surgery performed after introduction of off-pump approach.

OBJECTIVE: To clarify the position of on-pump beating coronary artery bypass (CAB) and to define preoperative indicators of intentional conversion to the procedure in the era of advancement of off-pump CAB (OPCAB), we assessed on-pump beating CAB performed after the introduction of OPCAB. SUBJECTS AND METHODS: We assessed 130 patients who underwent single CAB [117 (90%) with OPCAB and 13 (10%) with on-pump beating CAB] between August 1999 (when OPCAB was selected as the first-line surgical procedure) and December 2004. RESULTS: No significant differences were seen between the groups in the number of coronary lesions or the prevalence of left main trunk (LMT) lesion. Reduced left cardiac function, cardiac dilatation, and mitral regurgitation (MR) were more remarkable in the on-pump beating CAB group. Preoperative ischemic condition was generally unstable in the both groups. A conversion to on-pump beating CAB occurred at anastomosis for the left anterior descending (LAD) branch in 61% and for the left circumflex (LCX) branch in 15%. LAD patients had more severe left cardiac dysfunction and cardiac dilatation than LCX patients. CONCLUSION: To perform safe and reliable CAB surgery, cardiovascular surgeons should define preoperative indicators of difficult OPCAB and convert OPCAB to on-pump beating CAB intentionally without hesitation when unstable hemodynamics is detected.

A case report of emergency off-pump CABG in an aged patient with ACS renewing ventricular fibrillation.

An emergency off-pump coronary artery bypass (OPCAB) was performed successfully in an aged patient with acute coronary syndrome (ACS). The patient, an 80-year-old woman residing in a nursing home, suddenly lost consciousness during lunch. The electrocardiogram (ECG) showed ventricular fibrillation (Vf) but defibrillation successfully recovered the sinus rhythm. The patient was brought to our hospital as an emergency. She underwent emergency cardiac catheterization. Coronary angiography demonstrated severe three vessel disease with left main coronary trunk (LMT) stenosis. Even during intra-aortic balloon pumping (IABP), the hemodynamic state was unstable, with repeated development of ventricular tachycardia and fibrillation. An emergency coronary artery bypass without a cardiopulmonary bypass was performed. Saving her life was of primary importance and revascularization of the left anterior descending artery (LAD) branch, was performed. Thanks to the advances made in various devices, safe and reliable anastomoses have become possible in OPCAB applied to ACS. OPCAB for ACS have become safe and reliable anastomoses following development of various devices. We think that OPCAB is an effective surgical technique for coronary revascularization for emergency or serious cases involving elderly patients.

Limitations of retrograde continuous tepid blood cardioplegia for myocardial remodeling.

OBJECTIVE: We assessed potential limitations of retrograde continuous tepid blood cardioplegia (RCTBC) for myocardial remodeling, represented by hypertrophied and/or dilated myocardium in patients with severe cardiomyopathy following single aortic valve replacement. METHODS: The study was conducted on 91 patients who underwent initial single aortic valve replacement with tepid cardiopulmonary bypass (CPB) and RCTBC. Based on the postoperative maximum creatine phosphokinase (max CPK)-MB level, the patients were allocated to Group H (>/=100 IU/mL) with severe cardiomyopathy or Group L (<100 IU/mL) to make intergroup comparisons of preoperative, intraoperative, and postoperative parameter values. RESULTS: Preoperative measurements were as follows: pressure gradient between left ventricle and aorta (DeltaPG), 92.8+/-46.2 mmHg in Group H and 57.9+/-41.6 mmHg in Group L (p<0.01); implanted valve size, 21.0+/-2.2 mm in Group H and 22.8+/-2.2 mm in Group L (p<0.01); left ventricular end-diastolic volume (LVEDV), 155.7+/-73.3 mL in Group H and 224.3+/-101.5 mL in Group L (p<0.01). The rate of RCTBC flow rate increase did not differ between the groups (17.6% in Group H and 20.7% in Group L), while the rate of concomitant use of optional antegrade coronary perfusion was significantly lower in Group H (25%) than in Group L (37%) (p<0.05). Pre- and post-perfusion lactic acid levels in the myocardial protection solution measured every 30 min after aortic cross clamping were higher in Group H than in Group L. CONCLUSION: The study suggests preoperative high DeltaPG, small aortic root diameter, and low LVEDV, namely, concentrically hypertrophied myocardium, as risk factors for severe cardiomyopathy after RCTBC. RCTBC in patients with any risk factor should be accompanied by an increase in initial continuous perfusion flow and/or aggressive use of intermittent antegrade coronary perfusion.

Intravascular ultrasound imaging for detection of pseudoaneurysm with aortobronchopulmonary fistula after graft replacement of descending aorta.

A 63-year-old man had undergone graft replacement of the descending aorta due to dissection of aortic aneurysm nine years before and closure of an aortobronchopulmonary fistula two years before. He was admitted to our hospital because of massive hemoptysis. Angiography and chest computed tomography (CT) revealed a pseudoaneurysm on the proximal end caused by graft detachment. Intravascular ultrasound clearly revealed half round detachment on both ends of the graft. Replacement of the ascending, arch and distal aorta including the graft was performed, and the patient's postoperative course has been satisfactory. We have concluded that intravascular ultrasound is a useful method for detecting pseudoaneurysm after graft replacement which is not evident on cineangiography, CT or distal subtraction angiography.

L-arginine protects human heart cells from low-volume anoxia and reoxygenation.

Protective effects of L-arginine were evaluated in a human ventricular heart cell model of low-volume anoxia and reoxygenation independent of alternate cell types. Cell cultures were subjected to 90 min of low-volume anoxia and 30 min of reoxygenation. L-Arginine (0-5.0 mM) was administered during the preanoxic period or the reoxygenation phase. Nitric oxide (NO) production, NO synthase (NOS) activity, cGMP levels, and cellular injury were assessed. To evaluate the effects of the L-arginine on cell signaling, the effects of the NOS antagonist N(G)-nitro-L-arginine methyl ester, NO donor S-nitroso-N-acetyl-penicillamine, guanylate cyclase inhibitor methylene blue, cGMP analog 8-bromo-cGMP, and ATP-sensitive K+ channel antagonist glibenclamide were examined. Our data indicate that low-volume anoxia and reoxygenation increased NOS activity and facilitated the conversion of L-arginine to NO, which provided protection against cellular injury in a dose-dependent fashion. In addition, L-arginine cardioprotection was achieved by the activation of guanylate cyclase, leading to increased cGMP levels in human heart cells. This action involves a glibenclamide-sensitive, NO-cGMP-dependent pathway.