Managing postoperative atrial fibrillation after open-heart surgery using transdermal ß1 blockers.

BACKGROUND: Postoperative atrial fibrillation (POAF) after open-heart surgery is a non-negligible complication. We aimed to describe the efficacy of a transdermal patch of bisoprolol for managing POAF and flutter in thoracic surgical procedures. METHODS: We analyzed the data of 384 patients who underwent open-heart surgery at our hospital and received oral bisoprolol to prevent POAF. Among them, 65 patients (16.9%) also received a 4-mg transdermal patch of bisoprolol to control the heart rate due to POAF. We applied the bisoprolol transdermal patch when the heart rate was > 80 bpm and removed it at ≤ 60 bpm; an additional patch was applied when the heart rate was > 140 bpm. Heparin calcium injections were administered twice daily for anticoagulation between 2 and 6 days postoperatively. RESULTS: The average number of prescriptions for transdermal patches of bisoprolol during hospitalization was 1.8 ± 1.1 (1-5). The median first prescription date was on postoperative day 2 (range: days 0-37). Sinus rhythm recovered within 24 h in 18 patients (27.7%). Eight patients (12.3%) were switched to continuous landiolol infusion because of persistent tachycardia. In three patients, the transdermal patch was removed owing to severe bradycardia. Fifteen patients experienced persistent atrial fibrillation and were treated with electrical cardioversion during hospitalization. We did not observe any serious complications that could be directly attributed to bisoprolol transdermal patch use. CONCLUSIONS: Single-use bisoprolol transdermal patch may help control the heart rate during the initial treatment of POAF after open-heart surgery.

Early and Midterm Outcomes of "No-Touch" Saphenous Vein Grafts in Japanese Institutions.

INTRODUCTION: There have been several attempts to overcome the poor graft patency of saphenous vein grafts. "No-touch" saphenous vein graft (NT-SVG) could be a solution to improve graft patency. We aimed to investigate the early and midterm outcomes of coronary artery bypass grafting (CABG) using NT-SVGs in our hospitals. METHODS: This is a retrospective study of 105 patients who underwent CABG using 130 NT-SVGs between August 2013 and December 2021. NT-SVGs were harvested with about a 5-mm margin of surrounding tissue on both sides of the vein with minimal manipulation. Then, the NT-SVG was dilated by natural arterial pressure without manual distension. After surgery, most of NT-SVGs were assessed by cardiac catheterization or multidetector computed tomography (MDCT) to determine early graft patency. Late graft assessments by MDCT were performed about every five years after surgery. RESULTS: The early graft patency of NT-SVGs was 100% (125/125); however, two cases of graft twisting were found. Both cases spontaneously resolved. Leg wound infections of NT-SVG harvesting site were seen in 6.2% of patients. Peripheral neuropathy of the legs such as skin numbness and tingling were frequently observed, which lasted up to one year, but no more than two years after surgery. The midterm graft patency of NT-SVGs was excellent (five-year patency of NT-SVGs was 95.8%). CONCLUSION: The early and midterm graft patency of NT-SVGs was satisfactory. Although leg wound complications can be seen on the harvesting NT-SVG site, the "no-touch" harvesting technique of SVG could improve graft patency and clinical outcomes of CABG.

[Early Experience of Robot-assisted Mitral Valve Surgeries in Our Local Hospital].

We report the early experience of robot-assisted mitral valve repair in our local hospital. It took about two years from the application for the robot-assisted cardiac surgery until the first case of robot-assisted mitral repair. Since July 2020 to June 2022, we have performed 23 cases of robot-assisted mitral valve repair with da Vinci Xi system. There was no hospital death. The mean cross-clamp and total operation time were 118±22 and 295±41 min, respectively. Pre-discharge echocardiograms showed none-to-mild residual mitral regurgitation (MR) in all patients. The mean post-operative hospital stay was 7.6±5 days. Robot-assisted mitral valve repair could safely be started in our hospital. Early results were acceptable. Further experiences will be needed to confirm the efficacy of robotic mitral valve repair.

A strategy to enable rapid healing and prevent recurrence of venous ulcers.

INTRODUCTION: Venous ulcers are often intractable. OBJECTIVE: The aim of this study was to retrospectively analyze the effectiveness of endovenous ablation, compression therapy, moist wound healing, and skin care in the management of venous ulcers. MATERIALS AND METHODS: Twenty-eight consecutive patients (10 male, 18 female; mean age, 70.1 years) with Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class C6 venous ulcer underwent endovenous ablation between December 2014 and August 2020. The main treatment strategies were radiofrequency ablation and varicectomy (including stab avulsion of incompetent perforating veins), use of compression therapy until complete healing was achieved, moist wound healing (washing the ulcer site and covering it with dressings twice daily), and skin care, taking into consideration the balance of the microbiome. RESULTS: Active venous leg ulcers (CEAP class C6) were diagnosed in 36 patients at the first visit. In 7 of these patients, compression therapy and use of strategies to promote moist wound healing resulted in ulcer healing by the day of the planned surgery. One patient was unable to quit smoking and, therefore, could not undergo surgery. After excluding these 8 patients, the authors analyzed the data from 28 patients who underwent endovenous ablation. The mean surgical time was 38.9 minutes, and the mean number of stab avulsion incision sites was 9.7. All ulcers healed within a median of 55.5 days (range, 13-365 days). Ulcer healing was achieved by 1 year in all 28 patients (100%). No ulceration recurred as of the final follow-up (median, 24.5 months [range, 3-66 months]). CONCLUSIONS: Endovenous ablation, adequate varicectomy (stab avulsion [maximum number of sites in 1 patient, 43]), compression therapy, moist wound healing, and skin care are effective in treating and preventing recurrence of venous ulcers.

Feasibility of incompetent perforator vein excision using stab avulsion.

OBJECTIVES: Whether incompetent perforator veins (IPVs) require treatment remains controversial. We retrospectively evaluated the feasibility of IPV excision performed using the stab avulsion technique without ligation and sutures in patients undergoing endovenous ablation (EA). METHODS: This was a single-center, retrospective, observational cohort study. EA was performed in 1503 consecutive patients, including 33 patients with ulcers, between December 2014 and May 2021. Varicectomy was performed using the stab avulsion technique; IPV cases were included. RESULTS: Stab avulsion was performed at a mean number of 11.4 ± 7.8 sites. No deep vein thromboses or pulmonary emboli were noted. The incidence of nerve injury was 0.3%. All 33 (100%) patients with ulcers achieved healing by 1 year (median: 55.5 days; range: 13-365 days). CONCLUSIONS: IPV excision via stab avulsion may be a viable option for treating varicose veins and ulcers. This technique offers multiple advantages, including simplicity, safety, and reduced healthcare costs.

Early and Midterm Outcomes of "No-Touch" Saphenous Vein Grafts in Japanese Institutions

ABSTRACT Introduction: There have been several attempts to overcome the poor graft patency of saphenous vein grafts. "No-touch" saphenous vein graft (NT-SVG) could be a solution to improve graft patency. We aimed to investigate the early and midterm outcomes of coronary artery bypass grafting (CABG) using NT-SVGs in our hospitals. Methods: This is a retrospective study of 105 patients who underwent CABG using 130 NT-SVGs between August 2013 and December 2021. NT-SVGs were harvested with about a 5-mm margin of surrounding tissue on both sides of the vein with minimal manipulation. Then, the NT-SVG was dilated by natural arterial pressure without manual distension. After surgery, most of NT-SVGs were assessed by cardiac catheterization or multidetector computed tomography (MDCT) to determine early graft patency. Late graft assessments by MDCT were performed about every five years after surgery. Results: The early graft patency of NT-SVGs was 100% (125/125); however, two cases of graft twisting were found. Both cases spontaneously resolved. Leg wound infections of NT-SVG harvesting site were seen in 6.2% of patients. Peripheral neuropathy of the legs such as skin numbness and tingling were frequently observed, which lasted up to one year, but no more than two years after surgery. The midterm graft patency of NT-SVGs was excellent (five-year patency of NT-SVGs was 95.8%). Conclusion: The early and midterm graft patency of NT-SVGs was satisfactory. Although leg wound complications can be seen on the harvesting NT-SVG site, the "no-touch" harvesting technique of SVG could improve graft patency and clinical outcomes of CABG.

[Suspected Takotsubo Cardiomyopathy after Elective Mitral Valve Replacement:Report of a Case].

Reports of takotsubo cardiomyopathy following cardiac surgery are rare. We report a case of postoperative takotsubo cardiomyopathy after mitral valve replacement (MVR). The patient was a 70-yearold woman with mitral stenosis, regurgitation, and a medical history of long-standing persistent atrial fibrillation. Preoperative echocardiogram confirmed severe mitral regurgitation, severe mitral stenosis, severe tricuspid regurgitation, and slight left ventricular dysfunction. Coronary lesions were not observed on preoperative diagnostic coronary angiography. MVR with a bioprosthetic valve, tricuspid annuloplasty, and left atrial maze were performed. Electrocardiogram on postoperative day (POD) 1 revealed a deep negative T wave in V3-V6. Echocardiogram revealed "takotsubo-like" wall motion, and the ejection fraction( EF) was 19%. The EF improved on POD 7. After three months, the electrocardiogram findings and EF appeared normal. We suspected takotsubo cardiomyopathy although postoperative coronary angiography was not performed. Takotsubo cardiomyopathy should be considered as a possible complication of cardiac surgery, especially after MVR.

Strategy to prevent nerve injury and deep vein thrombosis in radiofrequency segmental thermal ablation of the saphenous veins using a new objective pain scale.

OBJECTIVE: We evaluated the benefit of local anesthesia including tumescent anesthesia and active walking soon after surgery in preventing nerve injury and deep vein thrombosis caused during endovenous ablation. METHODS: Endovenous ablation was performed in 1334 consecutive patients. Varicectomy was performed using the stab avulsion technique. After surgery, patients were encouraged to walk 100-200 m inside the ward for 3-5 times/h. The pain was evaluated objectively using the Okamura pain scale and subjectively using the numerical rating scale. RESULTS: Stab avulsion was performed at 11.8 ± 8.0 sites and the mean operative time was 33.9 ± 15.2 min. The mean Okamura pain scale and numerical rating scale scores were 1.6 ± 1.3 and 3.0 ± 2.0, respectively. Deep vein thrombosis and pulmonary embolism were absent. The incidence of nerve injury was 0.3%. CONCLUSIONS: Endovenous ablation should be performed with the patients under local anesthesia to prevent nerve injury and deep vein thrombosis.

Percutaneous Continuous Irrigation and Drainage for Infected Obturator Bypass Graft.

The treatment for obturator bypass graft infection has been rarely reported and is a surgical challenge because it is difficult to debride infected tissue around the graft located in the deep route and to ensure an alternative revascularization route in patients with a history of inguinal infection. Percutaneous continuous irrigation and drainage is an effective and less invasive definitive therapy for obturator bypass graft infection.

Chronic optical pacing conditioning of h-iPSC engineered cardiac tissues.

The immaturity of human induced pluripotent stem cell derived engineered cardiac tissues limits their ability to regenerate damaged myocardium and to serve as robust in vitro models for human disease and drug toxicity studies. Several chronic biomimetic conditioning protocols, including mechanical stretch, perfusion, and/or electrical stimulation promote engineered cardiac tissue maturation but have significant technical limitations. Non-contacting chronic optical stimulation using heterologously expressed channelrhodopsin light-gated ion channels, termed optogenetics, may be an advantageous alternative to chronic invasive electrical stimulation for engineered cardiac tissue conditioning. We designed proof-of-principle experiments to successfully transfect human induced pluripotent stem cell derived engineered cardiac tissues with a desensitization resistant, chimeric channelrhodopsin protein, and then optically paced engineered cardiac tissues to accelerate maturation. We transfected human induced pluripotent stem cell engineered cardiac tissues using an adeno-associated virus packaged chimeric channelrhodopsin and then verified optically paced by whole cell patch clamp. Engineered cardiac tissues were then chronically optically paced above their intrinsic beat rates in vitro from day 7 to 14. Chronically optically paced resulted in improved engineered cardiac tissue electrophysiological properties and subtle changes in the expression of some cardiac relevant genes, though active force generation and histology were unchanged. These results validate the feasibility of a novel chronically optically paced paradigm to explore non-invasive and scalable optically paced-induced engineered cardiac tissue maturation strategies.

Prevention of abdominal aortic aneurysm progression by oral administration of green tea polyphenol in a rat model.

OBJECTIVE: Inflammation-mediated elastin destruction in the aortic medial layer is related to progression of abdominal aortic aneurysm (AAA). Epigallocatechin-3-gallate (EGCG), a major component of green tea polyphenols, reportedly increases elastin synthesis in vitro and may possess anti-inflammatory effects. We used a rat model to investigate whether EGCG could prevent AAA progression. METHODS: AAA was induced with administration of intraluminal elastase and extraluminal CaCl2 in male rats. Rats were randomly divided into a control group (n = 30) and an EGCG group (n = 30). In the EGCG group, an EGCG solution (20 mg/d) was administered orally to each rat from 2 weeks before AAA induction and continued 4 weeks beyond induction. RESULTS: The abdominal aortic diameter was significantly smaller in the EGCG group than in the control group on day 28 (2.9 ± 0.2 vs 2.3 ± 0.1 mm; P < .0001). The medial layer wall thickness and elastin content were significantly greater in the EGCG group than in the control group on day 28 (68.4 ± 13.6 vs 46.7 ± 13.4 µm [P < .001] and 20.3 ± 4.6 vs 9.5 ± 3.6% [P < .0001], respectively). Gene expression levels of tropoelastin and lysyl oxidase were significantly higher in the EGCG group immediately before AAA induction, indicating promoted elastoregeneration by EGCG administration (tropoelastin: 0.59 ± 0.36 control vs 1.24 ± 0.36 EGCG [P < .05], lysyl oxidase: 0.77 ± 0.45 control vs 1.34 ± 0.4 EGCG [P < .05]) (fold increase). Gene expression levels of inflammatory cytokines, including tumor necrosis factor-α and interleukin-1ß, were significantly downregulated in the EGCG group (1.82 ± 0.71 vs 0.97 ± 0.59 [P < .05] and 3.91 ± 3.24 vs 0.89 ± 0.59 [P < .05], respectively). On day 7, gene expression levels and gelatinolytic activity of matrix metalloproteinase 9 were significantly lower in the EGCG group (1.41 ± 0.86 vs 0.51 ± 0.42 [P < .05] and 1.00 ± 0.17 vs 0.29 ± 0.12 [P < .0001], respectively), whereas gene expression levels of tissue inhibitors of metalloproteinase-1 were significantly higher in the EGCG group (0.96 ± 0.11 vs 1.14 ± 0.09; P < .05). CONCLUSIONS: EGCG attenuated AAA progression in a rat model by preserving the aortic thickness and elastin content of the medial layer through regeneration of elastin, as mediated by anti-inflammatory effects, and subsequent reduction of matrix metalloproteinase activity.

Green Tea Polyphenol Prevents Diabetic Rats From Acute Kidney Injury After Cardiopulmonary Bypass.

BACKGROUND: Acute kidney injury (AKI) is a common complication accompanying cardiopulmonary bypass (CPB) and is independently associated with increased morbidity and death. Diabetes mellitus increases the risk for AKI after CPB. Epigallocatechin-3-gallate (EGCG) is a major component of the polyphenolic fraction of green tea, which possesses cardioprotective activities, as previously reported. We hypothesized that EGCG also possesses a renoprotective effect through its diverse biochemical properties and assessed the effect on renal function after CPB for diabetic rats. METHODS: Goto-Kakizaki rats developing type 2 diabetes mellitus were randomly assigned to one of the following groups: sham (n = 10), CPB (CPB alone, n = 9), or EGCG (CPB + EGCG, n = 10). CPB was conducted for 30 minutes at a flow rate of 100 mL/kg/min in the CPB and EGCG groups. Rats assigned to the EGCG group were administrated EGCG solution orally for 2 weeks before CPB. We evaluated renal biochemical or histologic changes at 24 hours after CPB. RESULTS: Compared with the CPB group, the EGCG group exhibited milder tubular injury histologically (p < 0.0001) and reduced expression of kidney injury molecule-1, a biomarker for renal tubular injury (p < 0.0001) and 8-hydroxy-2'-deoxyguanosine (p < 0.01), indicating attenuated oxidant stress. CONCLUSIONS: Preoperative oral administration of EGCG ameliorates AKI in a CPB model of diabetic rats through antioxidative properties. This simple method could be applied in a clinical setting as a prophylactic renal protection against AKI after CPB, especially for high-risk patients with diabetes mellitus.

Massive hematuria and shock caused by ilio-ureteral fistula in a patient with an isolated internal iliac artery aneurysm.

An emergent operation was performed on a 73-year-old woman with massive hematuria and serious shock. A computed tomography (CT) revealed that the cause of the shock was hemorrhage from an aneurysm into the ureter, with resultant massive hematuria. During surgery, we observed that the ureter was encased into the wall of the aneurysm, with exposure of the pre-positioned ureteric stent inside the aneurysmal space. Reconstruction of the ureter was performed by wrapping the tissues with the ureteric stent inside. Postoperative recovery was uneventful, and CT angiography showed complete exclusion of the right internal iliac artery with the in situ ureteric stent.

Left atrial papillary fibroelastoma accidentally diagnosed with gastric cancer.

Papillary fibroelastoma is a rare but benign cardiac tumor and usually originates from the cardiac valve. We describe a 78-year-old woman who was initially diagnosed with gastric cancer, and was incidentally found to have a mass in the free wall of her left atrium between the left atrial appendage and the left superior pulmonary vein. An excision was performed through the left atrial appendage under cardiopulmonary bypass. The histopathologic examination of the resected tissue revealed a papillary fibroelastoma. The unusual localization of this papillary fibroelastoma was discussed.

Perfect and least invasive sealing technique on the lesser curvature of the aortic arch: application of a novel stent graft to an aneurysm developing on a postoperative ductus arteriosus.

A 78-year-old woman who underwent an operation for a patent ductus arteriosus (PDA) about thirty years ago developed an aneurysm on the aortic side of the remnant ductal tissue. To avoid risky, open surgery, we performed endovascular aortic therapy using a novel stent graft (SG), which was pre-curved, fenestrated and custom-made type. This graft was designed to configure to the patient's whole aortic arch anatomy, and was capable of accurately adjusting its fenestrations to the arch branch orifices during the procedure. The operation was successful, and the patient was discharged uneventfully on 16th postoperative day. The advantage of this fenestrated SG is close sealing, especially over the lesser curvature of the arch. This device could be a simple and effective option to deal with an otherwise normal aortic arch with such a ductus-related localized lesion.

Mesenteric artery fenestration for type B dissection with visceral ischemia.

We describe a successful case of direct superior mesenteric artery fenestration for an acute type B dissection complicated by bowel necrosis in a 68-year-old man. At 11 days after the onset, computed tomography showed superior mesenteric artery obstruction. We fenestrated and connected the true lumen to the false lumen of the superior mesenteric artery, and performed thrombectomy in both lumens. A bowel resection was carried out immediately. The patient was discharged uneventfully after recovery.