The necessity of routine screening for deep vein thrombosis before surgery.

Background: Pulmonary embolism (PE) from deep venous thrombosis (DVT) can be a fatal postoperative complication. Preventive measures for venous thromboembolism (VTE) was evaluated in this hospital. Materials and methods: Preoperative DVT screening following surgery under general anesthesia in 2009-2016 was examined, and then, 217 patients diagnosed with DVT by preoperative leg-ultrasound (US) between 2014 and 2016 were retrospectively analyzed. Results: There were 24,826 operations under general anesthesia in the study period. Preoperative leg-US was performed in 5345 (21.5%) patients, and 648 (12.1% of patients, 2.6% of total operations) were diagnosed with DVT. In 2014-2016, 217 patients, which is 11.7% of patients undergoing leg-US, were diagnosed with DVT. DVT was found in the proximal veins (upper popliteal vein) in 86 (39.6%) patients. A total of 143 (62%) patients were considered to have organized thrombi, no patient developed pulmonary embolism, and 133 (58%) patients were discharged without follow-up examination for DVT. Ninety-six patients were evaluated for changes on leg-US, with no difference in the results with and without anticoagulant use. On multivariate logistic regression analysis, anticoagulants appeared effective for non-organized thrombi, higher D-dimer levels (≥10 µg/mL), or orthopedic surgery. Conclusion: Preoperative screening for DVT did not appear useful, and treatment of asymptomatic DVT was not always necessary.

[Hybrid Coronary Revascularization of Minimally Invasive Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in a Patient with Left Main Coronary Stenosis].

We report a successful case of hybrid coronary revascularization of minimally invasive coronary artery bypass grafting( MICS-CABG) and percutaneous coronary intervention(PCI). The patient was a 78-year-old man with angina pectoris due to left main trunk (LMT) lesion, and had a history of repeated PCI to the left anterior descending artery (LAD) and the left circumflex artery (LCX) for angina pectoris. He presented with a chest pain on effort in June, 2015. A coronary angiogram showed a severe stenosis in the LMT extending to LAD and LCX. We performed hybrid therapy of CABG to LAD, and PCI to LMT and the proximal portion of LCX because the lesion was technically and suitable for PCI. CABG to LAD was performed via left mini thoracotomy using the left inter mammary artery (LIMA). LIMA was harvested under 3-dimentional endoscope. On the 5th post-operative day, PCI was performed to LMT and LCX. The postoperative course was uneventful and he was discharged on the 11th post-operative day. This case suggests that hybrid coronary revascularization is less invasive and feasible for selected patients with multi-vessel disease.

Transcatheter aortic valve implantation in a patient with aplastic anemia.

Aplastic anemia is a syndrome involving pancytopenia caused by bone marrow insufficiency. Pancytopenia increases the surgical risk of bleeding and infection. Here, we report a successful transcatheter aortic valve implantation (TAVI) in a patient with aplastic anemia. The patient was a 76-year-old woman who was admitted to our hospital with syncope. Laboratory testing showed pancytopenia, and echocardiography revealed severe aortic valve stenosis. Although the log.EuroSCORE and STS Score were not overly high, because of the presence of pancytopenia, surgical aortic valve replacement was considered too high risk, making her a candidate for TAVI. In this case, the patient's pancytopenia was so severe that even TAVI without preparation was considered high risk. In light of this, we carried out a two-day preoperative administration of granulocyte colony-stimulating factor and transfused packed red blood cells and platelet concentrates. TAVI was performed via the left femoral artery using the cut-down procedure under general anesthesia. The postoperative course was uneventful, and she was discharged on the sixth postoperative day. With adequate preoperative preparation, TAVI may be performed safely in high-risk patients with hematologic disorders. .

Implantable cardioverter defibrillator for progressive hypertrophic cardiomyopathy in a patient with LEOPARD syndrome and a novel PTPN11 mutation Gln510His.

LEOPARD syndrome (LS), generally caused by heterozygous mutations in the PTPN11 gene, is a rare autosomal-dominant multiple congenital anomaly condition, characterized by skin, facial, and cardiac abnormalities. Prognosis appears to be related to the type of structural, myocardial, and arrhythmogenic cardiac disease, especially hypertrophic cardiomyopathy (HCM). We report on a woman with LS and a novel Gln510His mutation in PTPN11, who had progressive HCM with congestive heart failure and nonsustained ventricular tachycardia, successfully treated with implantable cardioverter defibrillator (ICD). Comparing our patient to the literature suggests that specific mutations at codon 510 in PTPN11 (Gln510Glu, Gln510His, but not Gln510Pro) might be a predictor of fatal cardiac events in LS. Molecular risk stratification and careful evaluations for an indication of ICD implantation are likely to be beneficial in managing patients with LS and HCM.

Risk evaluation for coronary artery disease in patients with impaired glucose tolerance after a successful coronary intervention.

PURPOSE: Patients with coronary artery disease (CAD) often have risk factors that may influence endothelial function. The purpose of this study was to evaluate the endothelial function and its association with coronary risk factors after percutaneous coronary intervention (PCI). MATERIALS AND METHODS: A total of 14 patients with impaired glucose tolerance and CAD underwent positron emission tomography with N-13 ammonia to measure myocardial blood flow (MBF) at rest and during a cold pressor test (CPT), to estimate endothelial function as a percent increase (%increase) of MBF. The results were compared among normal segments (normal), reperfused segments with PCI (PCI), and nonculprit CAD segments without PCI (non-PCI). Correlations between the %increase and major risk factors were also investigated. RESULTS: CPT induced significant increase in MBF in all groups. The %increase of normal, non-PCI, and PCI groups were 33% ± 22%, 21% ± 23%, and 26% ± 23%, respectively. Comparison with risk factors demonstrated significant correlations only in the non-PCI group. Specifically, there were negative correlations between %increase and fasting blood sugar (r = -0.64, P < 0.05), hemoglobin A1c (r = -0.74, P < 0.05), total cholesterol (r = -0.87, P < 0.05), triglyceride (r = -0.71, P < 0.05), and low-density lipoprotein cholesterol (r = -0.92, P < 0.005), respectively. CONCLUSIONS: Although impaired glucose tolerance patients with a PCI-treated coronary stenosis showed preserved response to CPT, the %increase negatively correlated with risk factors in the non-PCI segments. Therefore, coronary risk factors may affect CAD lesions in PCI-treated patients.

Assessment of left ventricular dyssynchrony in patients with coronary artery disease during adenosine stress using ECG-gated myocardial perfusion single-photon emission computed tomography.

OBJECTIVES: Some investigators have reported that left ventricular (LV) mechanical systolic and diastolic dyssynchrony occurs in coronary artery disease (CAD) patients without earlier myocardial infarction and narrow QRS complex duration. However, earlier studies evaluated LV dyssynchrony only at rest. The purpose of this study was to investigate LV dyssynchrony in CAD patients with preserved ejection fraction during adenosine stress using electrocardiogram-gated myocardial perfusion single-photon emission computed tomography (SPECT). METHODS: The study population included 18 CAD patients and 18 control subjects. CAD patients had significant stenosis in their coronary arteries by coronary angiogram without earlier myocardial infarction. SPECT images were acquired at rest and during stress with adenosine. The regional time to end systole (TES), time to peak ejection, the time from 0 to peak filling during the whole diastolic period (TPF1), and the time from end systole to peak filling during the whole diastolic period (TPF2) were obtained by using the Quantitative Gated SPECT software. The maximal difference (MD), which is the difference between the earliest and latest temporal parameter among 17 segments, was considered to represent LV dyssynchrony. RESULTS: MD-TES and MD-TPF1 during stress were significantly greater than those of rest in CAD patients (MD-TES: stress=242+/-107 ms, rest=164+/-79 ms; P=0.005, MD-TPF1: stress=249+/-121 ms, rest=164+/-88 ms; P=0.015) but there were no significant differences in control patients. CONCLUSION: LV dyssynchrony was shown in CAD with preserved ejection fraction during adenosine stress.

Noninvasive evaluation of coronary endothelial function following sirolimus-eluting stent implantation by using positron emission tomography.

OBJECTIVE: Several invasive studies have reported delayed reendothelialization and endothelial dysfunction following sirolimus-eluting stent (SES) implantation. We evaluated the changes in coronary endothelial function following SES implantation by using a noninvasive method that involved positron emission tomography and cold pressor testing (CPT). METHODS: The study was conducted on 14 lesions on which percutaneous coronary intervention (PCI) was successively performed. The lesions were classified into 2 groups depending on the PCI performed: the conventional PCI group, in which 7 conventional PCIs (plain old balloon angioplasty or bare-metal stents) were performed, and the SES group, in which 7 SESs were implanted. Coronary endothelial function was defined as the percent increase in the myocardial blood flow (MBF) during CPT. RESULTS: The resting MBF in the segments distal to the PCI sites did not differ between the conventional PCI and SES groups; however, the MBF significantly decreased in the SES group during CPT. CONCLUSIONS: These data suggest that SES implantation induces coronary endothelial dysfunction in the segments distal to the PCI sites.

Successful treatment of primary cardiac angiosarcoma with docetaxel and radiotherapy.

A 49-year-old man was admitted for primary cardiac angiosarcoma with a cardiac tamponade. Transthoracic echocardiography and contrast-enhanced computed tomography scan demonstrated a large mass in the right atrium and thickening of the right ventricular wall. 18F-labeled deoxyglucose (FDG) positron emission tomography (PET) scan showed increased FDG uptake in the mediastinum and over the heart. The patient responded to combination therapy with docetaxel and radiotherapy and tolerated the treatment well, except for radiation esophagitis, which required a soft diet and resolved 1 month after treatment. This combination therapy resulted in a minimal response with slight regression in the tumor size, but FDG-PET initially showed an increase in FDG uptake by the tumor that was no longer seen after combination therapy. There is no evidence of progression or metastasis even at 12 months after diagnosis.