A novel transit-time flow metric, diastolic resistance index, detects subcritical anastomotic stenosis in coronary artery bypass grafting.

Objective: Transit time flow measurement (TTFM) can detect critical anastomotic stenosis during coronary artery bypass grafting. However, the identification of subcritical stenosis remains challenging. We hypothesized that diastolic resistance index (DRI), a novel TTFM metric, is more effective in evaluating subcritical stenosis than the currently available TTFM metrics. DRI is used to measure changes in the diastolic versus systolic resistance of distal anastomosis. Methods: A total of 123 coronary bypass anastomoses in 35 patients were prospectively analyzed. During coronary artery bypass grafting, the mean graft flow (Qmean), pulsatility index, and diastolic filling were obtained. DRI was calculated using the intraoperative recordings of TTFM and arterial pressure. Postoperatively, stenosis of anastomoses was categorized into successful (<50%), subcritical (50%-74%), and critical (≥75%) via multidetector computed tomography scan. Results: In total, 93 (76%), 13 (10%), and 17 (14%) anastomoses were graded as successful, subcritical, and critical, respectively. DRI and diastolic filling could distinguish subcritical from successful anastomoses (P < .01 and < .01, respectively), whereas Qmean and pulsatility index could not (P = .12 and .39, respectively). The receiver operating characteristic curves were established to evaluate the diagnostic ability for detecting ≥50% stenosis. In left anterior descending artery grafting (n = 55), DRI had the highest area under the curve (0.91), followed by diastolic filling (0.87), Qmean (0.74), and pulsatility index (0.65). Conclusions: DRI and diastolic filling had a reliable diagnostic ability for detecting ≥50% stenosis during coronary artery bypass grafting. In left anterior descending artery grafting, DRI had a more satisfactory detection capability than other TTFM metrics.

Outcomes of abdominal aortic aneurysm repairs: Endovascular vs open surgical repairs.

BACKGROUND: Operative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution. METHODS: All AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed. RESULTS: We had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more. CONCLUSIONS: OSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate.

A Comparison of Outcomes Based on Vessel Type (Native Artery vs. Bypass Graft) and Artery Location (Below-Knee Artery vs. Non-Below-Knee Artery) Using a Combination of Multiple Endovascular Techniques for Acute Lower Limb Ischemia.

BACKGROUND: To evaluate outcomes of endovascular treatment (EVT) using a combination of multiple endovascular techniques for acute lower limb ischemia (ALLI) and to compare outcomes based on vessel type and artery location. METHODS: A total of 95 consecutive patients with ALLI (mean age, 72.0 years; 65 males; 104 lower limbs) who received emergency EVT using a combination of multiple endovascular techniques including thrombolysis, aspiration thrombectomy, stenting, and balloon angioplasty with or without surgical thromboembolectomy, between January 2005 and December 2017 were included. Vessel type was classified into native artery occlusion (native occlusion) and bypass graft occlusion (graft occlusion), including prosthetic and vein graft. Additionally, native arteries were categorized into below-knee occlusion and non-below-knee occlusion. Technical success, perioperative death (POD), ALLI-related death, amputation, amputation-free survival (AFS), and complications were compared according to vessel type (native occlusion vs. graft occlusion) and artery location (below-knee occlusion vs. non-below-knee occlusion). RESULTS: Of all patients with ALLI, 16.8% underwent a single endovascular technique, whereas 83.2% underwent a combination of multiple endovascular techniques. The technicalsuccess, POD, and ALLI-related death rates in the total number of patients were 94.7%, 11.6%, and 4.2%, respectively. A total of 67 patients (75 limbs) and 28 patients (29 limbs) were classified as having native occlusion and graft occlusion (prosthetic, 24 limbs; vein, 5 limbs), respectively. No significant differences in technical success (native occlusion: 92.5% vs. graft occlusion: 100%), POD (14.9% vs. 3.6%), and ALLI-related death (6.0% vs. 0%) were noted between native occlusion and graft occlusion. However, the 30-day AFS rate of native occlusion was significantly lower than that of graft occlusion (75.2% vs. 96.3%, P=0.01). The amputation rate (P=0.03) and AFS rate (P=0.03) of below-knee occlusion were significantly worse for below-knee occlusion patients than for non-below-knee occlusion patients. CONCLUSIONS: EVT using multiple endovascular techniques for ALLI is effective and safe. A combination of multiple endovascular techniques is crucial for successful treatment. However, native occlusion may have a lower AFS rate than graft occlusion, and below-knee occlusion may have a higher risk of amputation than non-below-knee occlusion.

Characteristics of Inter-Arm Difference in Blood Pressure in Acute Aortic Dissection.

BACKGROUND: An inter-arm difference in blood pressure (IADBP) is characteristic of acute aortic dissection (AAD), but the importance of which arm exhibits lower blood pressure (BP) and the mechanism underlying IADBP are not well understood. METHODS: We identified consecutive patients with chest and/or back pain and suspected acute cardiovascular disease whose BP had been measured in both arms. We retrospectively compared the characteristics of such patients with AAD (n=93) to those without AAD (non-AAD group, n=122). Additionally, we separately compared patients with type A AAD (TAAD group, n=58) or type B AAD (TBAD group, n=35) to the non-AAD group. The characteristics analyzed were patient background and IADBP-related factors, including systolic BP (SBP) in the right arm (R) and left arm (L), and R-L or L-R as IADBP. Computed tomography (CT) findings of AD extending to the brachiocephalic artery (BCA) and/or left subclavian artery (LSCA) were examined in patients with an IADBP. RESULTS: In a comparison of the TAAD group and non-AAD group, the prevalences of R <130 mm Hg (38% vs. 19%, p=0.009), L-R >15 mm Hg (19% vs. 8%, p=0.047), L-R >20 mm Hg (14% vs. 4%, p=0.029) were higher in the TAAD group. Multivariate analysis showed that L-R >15 mm Hg with R <130 mm Hg was independently associated with TAAD (OR 25.97, 95% CI 2.45-275.67, p=0.007). However, IADBP-related factors were not associated with TBAD. AAD patients with L-R >20 mm Hg all had TAAD, and all aortic dissection extended to the BCA just before the right common carotid artery on CT. CONCLUSIONS: IADBP was characterized by R

Repetitive aortic dissection in a patient with giant cell arteritis.

Giant cell arteritis is reportedly associated with thoracic aortic aneurysm and acute aortic dissection. We encountered a patient with giant cell arteritis who suffered acute aortic dissection three times within a short period. A pathological specimen of the ascending aorta taken at surgery for type A acute aortic dissection revealed the typical features of giant cell arteritis. Giant cell arteritis patients might be at greater risk of acute aortic dissection than healthy individuals.

Computational fluid dynamics simulations of flow distribution and graft designs in apicoaortic bypass.

OBJECTIVE: Apicoaortic bypass has double outlets and its graft design is similar to that of a left ventricular assist device (LVAD). The left ventricular apex to the descending aorta (LV-DsAo) bypass is widely used in apicoaortic bypass. In contrast, the left ventricular apex to the ascending aorta (LV-AsAo) bypass is standard in LVAD surgery. This study aimed to evaluate the graft designs of apicoaortic bypass and their effects on flow distribution and energy loss (EL). METHODS: A simulation study using computational fluid dynamics was performed on the geometry and hemodynamics data obtained from a 30-year-old patient who underwent a LV-DsAo bypass. The ratio of the cardiac output (CO) through the ascending aorta (AsAo) and apicoaortic conduit was set at 50:50, 30:70, and 10:90. Regional blood flow (RBF) and EL were calculated for the different distribution ratios. As an alternative to the LV-DsAo bypass, a virtual LV-AsAo bypass surgery was performed, and each parameter was compared with that of the LV-DsAo bypass. RESULTS: At a distribution ratio of 50:50, the RBF to the head and EL were 16.4% of the total CO and 62.0 mW in the LV-DsAo bypass, and 32.3% and 81.5 mW in the LV-AsAo bypass, respectively. The RBF to the head decreased with the CO through the AsAo in the LV-DsAo bypass, but it was constant in the LV-AsAo bypass. The EL increased inversely with the CO through the AsAo in both graft designs. CONCLUSION: The regional blood flow distribution was different, but the trend of the EL which increased inversely with the CO through the AsAo was similar between the LV-DsAo and LV-AsAo bypasses.

Histological properties of oscillating intracardiac masses associated with cardiac implantable electric devices.

BACKGROUND: There have been a few cases of echogenic cardiac implantable electric device (CIED) lead-associated oscillating intracardiac masses (ICMs) in leads imaged by echocardiography. The histological properties of ICMs could help clarify the etiological diagnosis. Although there is extensive literature on mass size, the histological properties of such masses have not been characterized. The aim of this research was to clarify the histological features of oscillating ICMs in CIED patients. METHODS: Preoperative echocardiography was performed in all candidates for CIED removal. In the patients with ICMs, specimens were obtained by 3 methods: direct tissue collection during open-heart surgery; tissue collection together with the CIED lead during transvenous extraction; and tissue collection by catheter vacuum during transvenous CIED removal. A standard histopathological examination of ICM tissue was performed. RESULTS: A total of 106 patients underwent lead removal in our institute (April 2009-March 2018); 14 patients had an ICM (13.2%), and 7 specimens were obtained in patients with CIED lead-related ICM. Following histological examination, 2 types of ICM were identified: one mainly composed of thickened endocardium (EN type; 3 patients), and the other mainly an aggregate of inflammatory cells as a neutrophil cell (NC type; 4 patients). CONCLUSIONS: Two histological types of intracardiac masses, including a thickened endocardium type and a neutrophil cell type, were identified. These classifications might help make an accurate histological diagnosis of lead-associated intracardiac masses.

Long-term outcomes of endovascular aortic aneurysm repair with the Zenith AAA endovascular graft: a single-center study.

PURPOSE: To present long-term results obtained with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) using the Zenith AAA endovascular graft from a single institution. MATERIALS AND METHODS: Between 2007 and 2013, 95 consecutive patients (median age 77 years) underwent EVAR using Zenith. Data were prospectively collected and retrospectively analyzed until 2019. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes were freedom from late (> 30 days) re-intervention and surgical conversion, and freedom from aneurysm sac growth (> 5 mm). RESULTS: The initial technical success rate was 96.8%. There were no deaths or intraoperative conversions. Overall survival at 1, 3, 5, and 10 years was 90.8%, 81.7%. 74.3%, and 57.2%, respectively. AAA rupture occurred in one patient (1.1%). Freedom from AAA-related death was 100% during the follow-up period. Freedom from aneurysm sac growth at 1, 3, 5, and 10 years was 98.8%, 86.4%, 76.9%, 53.0%, respectively. Freedom from late re-intervention and open surgical conversion at 1, 3, 5, and 10 years was 98.9%, 88.9%, 86.7, and 57.9%, respectively. CONCLUSION: EVAR with Zenith endografts represents a safe and durable means of AAA repair, and risk of rupture and aneurysm-related death are low.

Surgical procedure for targeting arrhythmogenic substrates in the treatment of ventricular tachycardia associated with cardiac tumors.

BACKGROUND: Complete tumor resection is a standard strategy in the surgical treatment of ventricular tachycardia (VT) associated with cardiac tumors. Recently, an intraoperative electroanatomic mapping system (CARTO) has enabled surgeons to target the localized arrhythmogenic substrate for partial resection and/or cryoablation in nonresectable cardiac tumors. OBJECTIVE: The purpose of this study was to evaluate the surgical procedures and late outcomes of the treatment of VT associated with cardiac tumors. METHODS: We examined six patients (age 1-65 years) who had undergone surgical treatment of VT associated with cardiac tumors between 2010 and 2016. The 4 pathologies of the cardiac tumors were lipoma 2, fibroma 2, hemangioma 1, and lymphoma 1. Intraoperative epicardial mapping using CARTO was performed in 5 patients(80%). Surgical procedures and long-term outcomes were evaluated. RESULTS: Arrhythmogenic substrates with abnormal electrograms, such as fractionated or late potential, were identified locally or circumferentially beside the tumor in every patient. Complete tumor resection with cryoablation was performed in 3 patients. Two patients underwent partial tumor resection with cryoablation. Cryoablation without tumor resection was performed in 1 patient. No mortality and morbidity occurred. Additional catheter ablation was required in 2 patients to treat occurrence of nonclinical VT and induction of clinical VT during hospital stay. Mean follow-up time was 90 ± 52.5 months. There was no recurrence of clinical VT. CONCLUSION: The outcomes of surgical treatment of VT associated with cardiac tumors were excellent. Intraoperative CARTO mapping was beneficial to eliminate the VT substrates associated with nonresectable cardiac tumors.

An Extremely Rare Complication: Abdominal Aortic Aneurysm Rupture Caused by Migration of a Zenith Main Body Years After Repair of the Suprarenal Stent Separation.

PURPOSE: To report an unusual case of an abdominal aortic aneurysm (AAA) rupture caused by migration of a Zenith stent-graft main body years after its separation from the suprarenal stent. CASE REPORT: A 72-year-old man underwent endovascular aneurysm repair with a Zenith stent-graft for an infrarenal AAA in year 2000. At that time, a femorofemoral bypass was performed because the left external iliac and common femoral arteries were dissected during treatment. In 2013, follow-up computed tomography (CT) showed disconnection of the uncovered proximal stent, which led to a type Ia endoleak. An additional Zenith main body and Large Palmaz XL balloon-expandable stent were deployed; the endoleak disappeared. In 2016, the patient had abdominal pain, and emergency CT showed AAA rupture caused by migration of the first main body deployed in 2000 under the distal edge of the contralateral (left) leg of the additional main body from 2013, which led to a type IIIa endoleak between the 2 main bodies. A converter and iliac legs were deployed to successfully seal the type IIIa endoleak. The patient remains well 18 months after the second repair; CT scans document stable stent-grafts and no endoleak. CONCLUSION: Physicians should be aware of the potential risk for AAA rupture caused by late main body migration after treatment for suprarenal stent separation from a Zenith stent-graft.

Endovascular Treatment Strategy Using Catheter-Directed Thrombolysis, Percutaneous Aspiration Thromboembolectomy, and Angioplasty for Acute Upper Limb Ischemia.

PURPOSE: To evaluate the usefulness and safety of endovascular treatments for acute upper limb ischemia (AULI) by using multiple techniques, and to compare catheter-directed thrombolysis (CDT) and percutaneous aspiration thromboembolectomy (PAT) as initial procedures. MATERIALS AND METHODS: The study included 18 patients (4 men and 14 women) with AULI, who underwent a total of 20 sessions of endovascular treatment using various endovascular techniques between January 2005 and April 2016. The patients were initially treated with CDT [n = 9, CDT-based group (C-G)], PAT [n = 6, PAT-based group (P-G)], or angioplasty (n = 3). In case of residual emboli, we performed additional endovascular techniques. We assessed technical success, clinical success, and complications. Additionally, we compared the urokinase dosage between the groups. RESULTS: The mean patient age was 74.4 years. Technical and clinical success was obtained in all patients. Among the 18 patients, 1 underwent CDT only, 2 underwent PAT only, 1 underwent angioplasty only, and 14 underwent multiple techniques. Two patients from the C-G experienced major complications (cerebellar hemorrhage 1; pseudo-aneurysm in a branch of the ulnar artery 1). The mean urokinase dosage was lower in the P-G than in the C-G (40,000 vs. 246,667 IU; Mann-Whitney U test, P = 0.004). CONCLUSION: Endovascular treatment is effective and safe for AULI. A combination of multiple endovascular techniques is important for successful treatment. PAT is suggested as an initial procedure among endovascular techniques, in terms of a lower dosage of urokinase and a lower complication rate. LEVEL OF EVIDENCE: IV, Case-control studies.

[Coronary Artery Revascularization with V-composite Saphenous Veins Graft in a Bad Ascending Aorta;Report of a Case].

A 77-year-old male with many comorbidities underwent off pump coronary artery bypass grafting. A severely atherosclerotic ascending aorta was revealed by preoperative computed tomography(CT) and epiaortic echography during operation. Therefore, V-composite saphenous vein grafting was adopted for non left anterior descending artery (LAD) coronary lesions in addition to left internal thoracic artery-left anterior descending artery bypass grafting. He was discharged with no complications and all grafts were confirmed to be patent by postoperative CT. V-composite saphenous vein grafting for avoiding cerebrovascular complications might be one of the useful options in coronary artery revascularization for non-LAD lesions in elderly patients or those with many comorbidities, especially with a severely atherosclerotic ascending aorta.

Efficacy of Computed Tomography-Guided Catheter Drainage as the Initial Intervention and of Omentopexy as the Staged Surgery for a Prosthetic Graft Infection of Very Late Onset.

On the basis of computed tomography (CT) examination, a prosthetic graft infection of very late onset was suspected in a 72-year-old man who had undergone replacement of an bifurcated prosthetic graft 6 years earlier because of an abdominal aortic aneurysm and bilateral common iliac artery aneurysms. Emergency CT-guided needle aspiration was performed, and analysis of directly aspirated fluid confirmed the rapid diagnosis. Instead of conventional emergency surgery, CT-guided catheter drainage was the initial treatment and led to the gradual improvement of symptoms and laboratory data. Elective staged surgery was performed later to examine the cavity around the prosthetic graft. The cavity was then filled with in-situ omentum. Thus, CT-guided catheter drainage as the initial treatment and following omentopexy as the staged surgery avoided the need for highly invasive conventional surgery.

Long-term outcome after the original and simple modified technique of valve-sparing aortic root reimplantation in Marfan-based population, David V University of Tokyo modification.

BACKGROUND: In valve-sparing aortic root replacement (VSARR), how to reproduce Valsalva sinus has been an issue. In the original David V procedure, they put plication stitches at sinotubular junction level, although the reefing effect is limited and distal graft remains larger than native. Other modified techniques are two-grafts technique and ready-made Valsalva graft. However, the former needs graft-graft anastomosis and may not be cost-effective, while in the latter, the shape of sinus is fixed and minor adjustment is difficult. David V University of Tokyo modification (David V-UT) is our original solution to that, creating pseudosinus with one straight graft by longitudinal size-reduction running sutures above each pseudosinus. The purpose of the present study is to investigate long-term outcome of David V-UT. METHODS: We analyzed 59 David V-UT patients from February 2004 to February 2013 and long-term outcomes were investigated by Kaplan-Meier methods. Risk factors for adverse events "death or recurrent aortic insufficiency (AI) with or without aortic valve reoperation" were analyzed by using Cox proportional hazard models. RESULTS: Mean age was 33.1±14.5 years, and 38 patients (64%) were male. Marfan syndrome (MFS) accounts for 47 patients (80%). Only one patient was with bicuspid aortic valve. No in-hospital mortality was observed. Mean follow-up was 4.9±2.4 years. Estimated survival was 94.0±3.4% at 5 years. Freedoms from aortic valve reoperation and recurrent AI greater than mild were 95.7±3.0% and 88.9±4.7% at 5 years, respectively. In Cox proportional hazard analysis, preoperative AI greater than mild and Z score of annular diameter were significant risks for adverse events (p=0.027 and 0.045, hazard ratio 6.084 and 1.432, 95% C.I. 1.225-30.21 and 1.008-2.035, respectively). CONCLUSIONS: Even in Marfan-characterized population, David V-UT provided satisfactory long-term outcome, comparable to other VSARR modifications. It is simple but can freely reproduce trilobed sinus with one straight graft.

Exploration of theoretical ganglionated plexi ablation technique in atrial fibrillation surgery.

BACKGROUND: Ganglionated plexi ablation during atrial fibrillation surgery is not technically standardized for precise ganglionated plexi locations or ablation sequence. We aimed to identify precise active ganglionated plexi locations in patients with structural heart disease and explore the feasibility of anatomic ganglionated plexi ablation without prior mapping in patients with atrial fibrillation. METHODS: Thirty patients with valvular disease-associated atrial fibrillation underwent ganglionated plexi ablation and a modified maze procedure. In 20 patients, ganglionated plexi mapping was performed to identify active plexi. According to mapping results, anatomically determined plexi were ablated without mapping in the final 10 patients. Ganglionated plexi ablation outcomes with and without prior mapping were compared between perioperative and early postoperative periods. RESULTS: Active ganglionated plexi common to more than 20% of patients were identified in the superior and inferior right pulmonary veins, superior left pulmonary vein, interatrial groove, and inferior left atrium. Inferior left atrial plexi ablation resulted in maximum vagal modulation. Compared with ablation using mapping, anatomic ablation yielded more vagal modulation in heart rate variability and decreased the requisite cardiopulmonary bypass time. CONCLUSIONS: The sequential pacing and ablation technique identified an optimal ablation sequence that best ensured vagal reflex elimination from all ganglionated plexi. Anatomic ablation using a predetermined ganglionated plexi map may be a viable alternative to individual plexus mapping before ablation.

Paraplegia prevention by oral pretreatment with memantine in a rabbit model.

OBJECTIVE: To evaluate the role of memantine (N-methyl-d-aspartate receptor antagonist) pretreatment for the prevention of spinal cord ischemia after infrarenal aortic clamping in a rabbit model. METHODS: Thirty New Zealand White rabbits were divided into 5 different groups of 6 rabbits. Groups 60-7 and 60-5 received oral memantine 60 mg once a day for 7 and 5 days, respectively, and groups 30-5 and 30-3 received oral memantine 30 mg once a day for 5 and 3 days, respectively, all before surgery. Group C (control) received normal feeds without memantine. A paraplegic model was created by clamping both the aorta and the inferior vena cava infrarenally and just proximal to their bifurcations for 45 minutes. The modified Tarlov score, motor evoked potential (MEP), serum memantine concentration, and histopathology of the spinal cord were evaluated. RESULTS: The mean modified Tarlov scores were 4.2±1.3, 4.3±1.0, 4.2±1.3, 4.3±1.2, and 0.8±1.6 in groups 60-7, 60-5, 30-5, 30-3, and C, respectively at 6, 24, 48, and 72 hours (P<.009 for individual groups vs control). Percentage amplitude loss of MEP by the end of surgery was 29.5%±46.3%, 11.9%±28.0%, 30.0%±46.8%, 16.7%±40.8%, and 81.8%±40.3% for the 5 groups, respectively (P=.049). After declamping, MEP reappeared in 83%, 100%, 83%, 83%, and 33% of cases in the 5 groups, respectively (P=.073). The serum memantine level was similar in the 4 memantine groups. Spinal cords were normal in most of the rabbits in groups 60-7, 60-5, 30-5, and 30-3, but severely ischemic in most of the rabbits in group C (P=.041). CONCLUSIONS: Oral memantine pretreatment is protective against spinal cord ischemia, and can be an additional strategy for the prevention of paraplegia during thoracoabdominal aortic surgeries.

Healing process of a novel zero-porosity vascular graft.

OBJECTIVES: We report on a study of thoracic aortic replacement in a canine model in order to demonstrate experimentally the process of tissue healing facilitated by the uniquely structured Triplex® graft. METHODS: Twelve Triplex® grafts were used in this study with 12 collagen-coated vascular grafts (Hemashield®, Boston Scientific, Natick, MA, USA) as the controls in 24 dogs; the grafts were taken out 4 or 26 weeks after implantation and were analysed histopathologically. RESULTS: The results demonstrate, at 4 weeks after implantation, that the degree of pseudointima formation was comparable between the Triplex® grafts and the control grafts, although significant inflammatory reactivity was observed in the control grafts. After 26 weeks of implantation, significant lymphocytic infiltration was found in one animal treated with a Triplex® graft and significant neutrophil infiltration was found in one animal implanted with a control graft. In the other animals implanted with Triplex® or control grafts, the observed inflammatory reactions were similar. Specifically, in both animals implanted with Triplex® or control grafts, significant numbers of immature mesenchymal cells, fibroblasts and collagen fibres were observed at 26 weeks after implantation, and foreign-body reactions found in animals implanted with the control graft at 4 weeks after implantation were not observed at 26 weeks after implantation. Thus, the xenobiotic property and the degree of encapsulation were comparable between both the animals implanted with the Triplex® graft and those treated with the control graft. CONCLUSIONS: Our study demonstrated that Triplex® vascular grafts, which have a unique structure that conventional grafts do not possess, induced mild inflammation in the acute phase after the implant compared with the control grafts, and contributed to tissue healing comparable with the control graft 26 weeks after implantation.

Impairment of flow-mediated dilation correlates with aortic dilation in patients with Marfan syndrome.

Marfan syndrome is an inherited disorder characterized by genetic abnormality of microfibrillar connective tissue proteins. Endothelial dysfunction is thought to cause aortic dilation in subjects with a bicuspid aortic valve; however, the role of endothelial dysfunction and endothelial damaging factors has not been elucidated in Marfan syndrome. Flow-mediated dilation, a noninvasive measurement of endothelial function, was evaluated in 39 patients with Marfan syndrome. Aortic diameter was measured at the aortic annulus, aortic root at the sinus of Valsalva, sinotubular junction and ascending aorta by echocardiography, and adjusted for body surface area (BSA). The mean value of flow-mediated dilation was 6.5 ± 2.4 %. Flow-mediated dilation had a negative correlation with the diameter of the ascending thoracic aorta (AscAd)/BSA (R = -0.39, p = 0.020) and multivariate analysis revealed that flow-mediated dilation was an independent factor predicting AscAd/BSA, whereas other segments of the aorta had no association. Furthermore, Brinkman index had a somewhat greater influence on flow-mediated dilation (R = -0.42, p = 0.008). Although subjects who smoked tended to have a larger AscAd compared with non-smokers (AscA/BSA: 17.3 ± 1.8 versus 15.2 ± 3.0 mm/m(2), p = 0.013), there was no significant change in flow-mediated dilation, suggesting that smoking might affect aortic dilation via an independent pathway. Common atherogenic risks, such as impairment of flow-mediated dilation and smoking status, affected aortic dilation in subjects with Marfan syndrome.