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BACKGROUND: The impact of very low baseline levels of low-density lipoprotein cholesterol (LDL-C) on patients with coronary artery disease remains unclear. METHOD: We enrolled 39,439 patients of the pooled population from the CREDO-Kyoto registries Cohorts 1, 2, and 3. The study population consisted of 33,133 patients who had undergone their first coronary revascularization. We assessed the risk for mortality and cardiovascular events according to quintiles of the baseline LDL-C levels. RESULTS: Patients in the very low LDL-C quintile (<85â¯mg/dL) had more comorbidities than those in the other quintiles. Lower LDL-C levels were strongly associated with anemia, thrombocytopenia, and end-stage renal disease. The cumulative 4-year incidence of all-cause death increased as LDL-C levels decreased (very low: 19.4â¯%, low: 14.5â¯%, intermediate: 11.1â¯%, high: 10.0â¯%, and very high: 9.2â¯%; pâ¯<â¯0.001), which was driven by both the early and late events. After adjusting for baseline characteristics, the adjusted risks of the very low and low LDL-C quintiles relative to the intermediate LDL-C quintile remained significant for all-cause death (very low: HR 1.29, 95â¯% CI 1.16-1.44, pâ¯<â¯0.001; low: HR 1.15, 95â¯% CI 1.03-1.29, pâ¯=â¯0.01). The excess adjusted risks of the lowest LDL-C quintile relative to the intermediate LDL-C quintile were significant for clinical outcomes such as cardiovascular death (HR 1.17, 95â¯% CI 1.01-1.35), non-cardiovascular death (HR 1.35, 95â¯% CI 1.15-1.60), sudden death (HR 1.44, 95â¯% CI 1.01-2.06), and heart failure admission (HR 1.11 95â¯% CI 1.01-1.22), while there was no excess risk for the lowest LDL-C quintile relative to the intermediate LDL-C quintile for myocardial infarction and stroke. CONCLUSIONS: Lower baseline LDL-C levels were associated with more comorbidities and a significantly higher risk of death, regardless of cardiovascular or non-cardiovascular causes, in patients who underwent coronary revascularization.
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LDL-Colesterol , Enfermedad de la Arteria Coronaria , Sistema de Registros , Humanos , LDL-Colesterol/sangre , Masculino , Femenino , Anciano , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/mortalidad , Pronóstico , Persona de Mediana Edad , Revascularización Miocárdica , Causas de Muerte , Japón/epidemiología , Factores de RiesgoRESUMEN
We present a case of a ruptured mycotic coronary aneurysm effectively treated with covered stents and phased surgery. The covered stent, however, became occluded two years later. Because of the low invasiveness, a covered stent treatment may be advantageous over conventional surgery but trade off long-term vascular patency. Learning objective: To recognize the presence of a ruptured infectious coronary aneurysm after a primary coronary stenting for ST-elevation myocardial infarction.To discuss the treatment strategies for a ruptured infectious coronary aneurysm with a covered stent.
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Background: Diabetes is a well-known risk factor for adverse outcomes after coronary revascularization. Objectives: This study sought to determine high-risk subgroups in whom the excess risks of diabetes relative to nondiabetes are particularly prominent and thus may benefit from more aggressive interventions. Methods: The study population consisted of 39,427 patients (diabetes: n = 15,561; nondiabetes: n = 23,866) who underwent first percutaneous coronary intervention (n = 33,144) or coronary artery bypass graft (n = 6,283) in the pooled CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Graft) registry. The primary outcome measure was major adverse cardiovascular and cerebral endpoints (MACCE), which was defined as a composite of all-cause death, myocardial infarction, and stroke. Results: With median follow-up of 5.6 years, diabetes was associated with significantly higher adjusted risks for MACCE. The excess adjusted risks of diabetes relative to nondiabetes for MACCE increased with younger age (≤64 years: adjusted HR: 1.30; 95% CI: 1.19-1.41; P < 0.001; 64-73 years: adjusted HR: 1.24; 95% CI: 1.16-1.33; P < 0.001; >73 years: adjusted HR: 1.17; 95% CI: 1.10-1.23; P < 0.001; P interaction < 0.001), mainly driven by greater excess adjusted mortality risk of diabetes relative to nondiabetes in younger tertile. No significant interaction was observed between adjusted risk of diabetes relative to nondiabetes for MACCE and other subgroups such as sex, mode of revascularization, and clinical presentation of acute myocardial infarction. Conclusions: The excess risk of diabetes relative to nondiabetes for MACCE was profound in the younger population. This observation suggests more aggressive interventions for secondary prevention in patients with diabetes might be particularly relevant in younger patients.
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AIMS: There is a scarcity of studies comparing percutaneous coronary intervention (PCI) using new-generation drug-eluting stents (DES) with coronary artery bypass grafting (CABG) in patients with multi-vessel coronary artery disease. METHODS AND RESULTS: The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who underwent first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. The current study population consisted of 2464 patients who underwent multi-vessel coronary revascularization including revascularization of left anterior descending coronary artery (LAD) either with PCI using new-generation DES (N = 1565), or with CABG (N = 899). Patients in the PCI group were older and more often had severe frailty, but had less complex coronary anatomy, and less complete revascularization than those in the CABG group. Cumulative 5-year incidence of a composite of all-cause death, myocardial infarction or stroke was not significantly different between the 2 groups (25.0% versus 21.5%, P = 0.15). However, after adjusting confounders, the excess risk of PCI relative to CABG turned to be significant for the composite endpoint (HR 1.27, 95%CI 1.04-1.55, P = 0.02). PCI as compared with CABG was associated with comparable adjusted risk for all-cause death (HR 1.22, 95%CI 0.96-1.55, P = 0.11), and stroke (HR 1.17, 95%CI 0.79-1.73, P = 0.44), but with excess adjusted risk for myocardial infarction (HR 1.58, 95%CI 1.05-2.39, P = 0.03), and any coronary revascularization (HR 2.66, 95%CI 2.06-3.43, P<0.0001). CONCLUSIONS: In this observational study, PCI with new-generation DES as compared with CABG was associated with excess long-term risk for major cardiovascular events in patients who underwent multi-vessel coronary revascularization including LAD.
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Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Infarto del Miocardio , Intervención Coronaria Percutánea , Accidente Cerebrovascular , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/efectos adversos , Sistema de RegistrosRESUMEN
OBJECTIVE: We assessed the clinical effectiveness of coronary artery bypass grafting (CABG) in comparison with that of percutaneous coronary intervention (PCI) in octogenarians with triple-vessel disease (TVD) or left main coronary artery (LMCA) disease. METHODS: From the CREDO-Kyoto registry cohort-2, 527 patients, who were ≥ 80 years of age and underwent the first coronary revascularization for TVD or LMCA disease, were divided into the CABG group (N = 151) and the PCI group (N = 376). RESULTS: The median and interquartile range of patient's age was 82 (81-84) in the CABG group and 83 (81-85) in the PCI group (P = 0.10). Patients > = 85 years of age accounted for 19% and 31% in the CABG and PCI groups, respectively (P = 0.01). The cumulative 5-year incidence of all-cause death was similar between CABG and PCI groups (35.8% vs. 42.9%, log-rank P = 0.18), while CABG showed a lower rate of the composite of cardiac death/MI than PCI (21.7% vs. 33.9%, log-rank P = 0.005). After adjusting for confounders, the lower risk of CABG relative to PCI was significant for all-cause death (HR 0.61, 95% CI 0.43-0.86, P = 0.005), any coronary revascularization (HR 0.25, 95% CI 0.14-0.43, P < 0.001) and the composite of cardiac death/MI (HR 0.52, 95% CI 0.32-0.85, P = 0.009). CONCLUSIONS: CABG compared with PCI was associated with a lower adjusted risk for all-cause death, any coronary revascularization, and a composite of cardiac death/MI in very elderly patients with TVD or LMCA disease. CABG seemed an acceptable option for selected octogenarians with severe coronary artery disease.
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Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Infarto del Miocardio , Intervención Coronaria Percutánea , Accidente Cerebrovascular , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Muerte , Humanos , Octogenarios , Intervención Coronaria Percutánea/efectos adversos , Accidente Cerebrovascular/epidemiología , Resultado del TratamientoRESUMEN
Acquired pulmonary vein (PV) stenosis (PVS) is a complication following cardiac catheter intervention. However, very few cases of PVS after surgical ablation have been reported. We herein report a case of stenosis and occlusion at the left atrium to each pulmonary vein after surgical ablation. A 73-year-old woman who had received aortic valve replacement and pulmonary vein isolation 10 months earlier was diagnosed with congestive heart failure accompanied by pulmonary hypertension. Contrast-enhanced computed tomography revealed stenosis and complete occlusion of the left atrium to all four pulmonary veins. Surgical repair was performed via pericardial patch reconstruction of the left atrium to each PV. Treating multiple PV lesions with involvement of the left atrium wall requires tailored methods. However, there have been few reports concerning such methods of reconstruction. We herein report a method of reconstructing the left atrium and pulmonary veins at the same time.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Estenosis de Vena Pulmonar , Anciano , Fibrilación Atrial/cirugía , Femenino , Atrios Cardíacos , Humanos , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/cirugía , Estenosis de Vena Pulmonar/diagnóstico por imagen , Estenosis de Vena Pulmonar/etiología , Estenosis de Vena Pulmonar/cirugía , Resultado del TratamientoRESUMEN
Background Heart failure might be an important determinant in choosing coronary revascularization modalities. There was no previous study evaluating the effect of heart failure on long-term clinical outcomes after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG). Methods and Results Among 14 867 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013 in the CREDO-Kyoto PCI/CABG registry Cohort-3, we identified the current study population of 3380 patients with three-vessel or left main coronary artery disease, and compared clinical outcomes between PCI and CABG stratified by the subgroup based on the status of heart failure. There were 827 patients with heart failure (PCI: N=511, and CABG: N=316), and 2553 patients without heart failure (PCI: N=1619, and CABG: N=934). In patients with heart failure, the PCI group compared with the CABG group more often had advanced age, severe frailty, acute and severe heart failure, and elevated inflammatory markers. During a median 5.9 years of follow-up, there was a significant interaction between heart failure and the mortality risk of PCI relative to CABG (interaction P=0.009), with excess mortality risk of PCI relative to CABG in patients with heart failure (HR, 1.75; 95% CI, 1.28-2.42; P<0.001) and no excess mortality risk in patients without heart failure (HR, 1.04; 95% CI, 0.80-1.34; P=0.77). Conclusions There was a significant interaction between heart failure and the mortality risk of PCI relative to CABG with excess risk in patients with heart failure and neutral risk in patients without heart failure.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Insuficiencia Cardíaca , Efectos Adversos a Largo Plazo , Intervención Coronaria Percutánea , Anciano , Comorbilidad , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Fragilidad/diagnóstico , Fragilidad/epidemiología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/fisiopatología , Humanos , Japón/epidemiología , Efectos Adversos a Largo Plazo/diagnóstico , Efectos Adversos a Largo Plazo/etiología , Efectos Adversos a Largo Plazo/mortalidad , Masculino , Evaluación de Resultado en la Atención de Salud , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
The treatment of coronary artery disease has substantially changed over the past two decades. However, it is unknown whether and how much these changes have contributed to the improvement of long-term outcomes after coronary revascularization. We assessed trends in the demographics, practice patterns and long-term outcomes in 24,951 patients who underwent their first percutaneous coronary intervention (PCI) (nâ¯=â¯20,106), or isolated coronary artery bypass grafting (CABG) (nâ¯=â¯4,845) using the data in a series of the CREDO-Kyoto PCI/CABG Registries (Cohort-1 [2000 to 2002]: nâ¯=â¯7,435, Cohort-2 [2005 to 2007]: nâ¯=â¯8,435, and Cohort-3 [2011 to 2013]: nâ¯=â¯9,081). From Cohort-1 to Cohort-3, the patients got progressively older across subsequent cohorts (67.0 ± 10.0, 68.4 ± 9.9, and 69.8 ± 10.2 years, ptrend < 0.001). There was increased use of PCI over CABG (73.5%, 81.9%, and 85.2%, ptrend < 0.001) and increased prevalence of evidence-based medications use over time. The cumulative 3-year incidence of all-cause death was similar across the 3 cohorts (9.0%, 9.0%, and 9.3%, pâ¯=â¯0.74), while cardiovascular death decreased over time (5.7%, 5.1%, and 4.8%, pâ¯=â¯0.03). The adjusted risk for all-cause death and for cardiovascular death progressively decreased from Cohort-1 to Cohort-2 (HR:0.89, 95%CI:0.80 to 0.99, pâ¯=â¯0.03, and HR:0.80, 95%CI:0.70 to 0.92, pâ¯=â¯0.002, respectively), and from Cohort-2 to Cohort-3 (HR:0.86, 95%CI:0.78 to 0.95, pâ¯=â¯0.004, and HR:0.77, 95%CI:0.67-0.89, p < 0.001, respectively). The risks for stroke and repeated coronary revascularization also improved over time. In conclusions, we found a progressive and substantial reduction of adjusted risk for all-cause death, cardiovascular death, stroke, and repeated coronary revascularization over the past two decades in Japan.
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Puente de Arteria Coronaria/tendencias , Enfermedad de la Arteria Coronaria/cirugía , Mortalidad/tendencias , Intervención Coronaria Percutánea/tendencias , Factores de Edad , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Causas de Muerte , Estudios de Cohortes , Comorbilidad/tendencias , Diabetes Mellitus/epidemiología , Terapia Antiplaquetaria Doble/tendencias , Duración de la Terapia , Medicina Basada en la Evidencia , Femenino , Insuficiencia Cardíaca/epidemiología , Hemorragia/epidemiología , Humanos , Hipertensión/epidemiología , Japón/epidemiología , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Revascularización Miocárdica/tendencias , Complicaciones Posoperatorias/epidemiología , Hemorragia Posoperatoria/epidemiología , Sistema de Registros , Diálisis Renal , Reoperación , Fumar/epidemiología , Stents , Accidente Cerebrovascular/epidemiología , Trombosis/epidemiologíaRESUMEN
There is a scarcity of data comparing long-term clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel coronary artery disease (3VD) in the new-generation drug-eluting stents era. CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who had undergone first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. We identified 2525 patients with 3VD (PCI: n = 1747 [69%], and CABG: n = 778 [31%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.7 (interquartile range: 4.4 to 6.6) years. The cumulative 5-year incidence of all-cause death was significantly higher in the PCI group than in the CABG group (19.8% vs 13.2%, log-rank p = 0.001). After adjusting confounders, the excess risk of PCI relative to CABG for all-cause death remained significant (HR, 1.45; 95% CI, 1.14 to 1.86; p = 0.003), which was mainly driven by the excess risk for non-cardiovascular death (HR, 1.88; 95% CI, 1.30 to 2.79; p = 0.001), while there was no excess risk for cardiovascular death between PCI and CABG (HR, 1.19; 95% CI, 0.87 to 1.64; p = 0.29). There was significant excess risk of PCI relative to CABG for myocardial infarction (HR, 1.77; 95% CI, 1.19 to 2.69; p = 0.006), whereas there was no excess risk of PCI relative to CABG for stroke (HR, 1.24; 95% CI, 0.83 to 1.88; p = 0.30). In conclusion, in the present study population reflecting real-world clinical practice in Japan, PCI compared with CABG was associated with significantly higher risk for all-cause death, while there was no excess risk for cardiovascular death between PCI and CABG.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Stents Liberadores de Fármacos , Mortalidad , Intervención Coronaria Percutánea , Anciano , Anciano de 80 o más Años , Causas de Muerte , Estudios de Cohortes , Femenino , Humanos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Modelos de Riesgos Proporcionales , Sistema de Registros , Accidente Cerebrovascular/epidemiologíaRESUMEN
Chronic kidney disease (CKD) might be an important determinant in choosing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). However, there is a scarcity of studies evaluating the effect of CKD on long-term outcomes after PCI relative to CABG in the population including severe CKD. Among 30257 consecutive patients patients who underwent first coronary revascularization with PCI or isolated CABG in the CREDO-Kyoto PCI/CABG registry Cohort-2 (n = 15330) and Cohort-3 (n = 14,927), we identified the current study population of 12,878 patients with multivessel or left main disease, and compared long-term clinical outcomes between PCI and CABG stratified by the subgroups based on the stages of CKD (no CKD: eGFR >=60 ml/min/1.73m2, moderate CKD: 60> eGFR >=30 ml/min/1.73m2, and severe CKD: eGFR <30 ml/min/1.73m2 or dialysis). There were 6,999 patients without CKD (PCI: n = 5,268, and CABG: n = 1,731), 4,427 patients with moderate CKD (PCI: n = 3,226, and CABG: n = 1,201), and 1,452 patients with severe CKD (PCI: n = 989, and CABG: n = 463). During median 5.6 years of follow-up, the excess mortality risk of PCI relative to CABG was significant regardless of the stages of CKD without interaction (no CKD: HR, 1.36; 95%CI, 1.12 to 1.65; p = 0.002, moderate CKD: HR, 1.40; 95%CI, 1.17 to 1.67; p <0.001, and severe CKD: HR, 1.33; 95%CI, 1.09 to 1.62; p = 0.004, Interaction p = 0.83). There were no significant interactions between CKD and the effect of PCI relative to CABG for all the outcome measures evaluated. In conclusion, PCI compared with CABG was associated with significantly higher risk for all-cause death regardless of the stages of CKD without any significant interaction.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Intervención Coronaria Percutánea , Insuficiencia Renal Crónica/epidemiología , Anciano , Anciano de 80 o más Años , Enfermedad de la Arteria Coronaria/epidemiología , Femenino , Tasa de Filtración Glomerular , Humanos , Japón/epidemiología , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Sistema de Registros , Diálisis Renal , Índice de Severidad de la EnfermedadRESUMEN
Long-term safety of percutaneous coronary intervention (PCI) as compared with coronary artery bypass grafting (CABG) is still controversial in patients with unprotected left main coronary artery disease (ULMCAD), and there is a scarcity of real-world data on the comparative long-term clinical outcomes between PCI and CABG for ULMCAD in new-generation drug-eluting stents era. The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013, and we identified 855 patients with ULMCAD (PCI: Nâ¯=â¯383 [45%], and CABG: Nâ¯=â¯472 [55%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.5 (interquartile range: 3.9 to 6.6) years. The cumulative 5-year incidence of all-cause death was not significantly different between the PCI and CABG groups (21.9% vs 17.6%, Log-rank p = 0.13). After adjusting confounders, the excess risk of PCI relative to CABG remained insignificant for all-cause death (HR, 1.00; 95% CI, 0.68 to 1.47; p = 0.99). There were significant excess risks of PCI relative to CABG for myocardial infarction and any coronary revascularization (HR, 2.07; 95% CI, 1.30 to 3.37; p = 0.002, and HR, 2.96; 95% CI, 1.96 to 4.46; p < 0.001), whereas there was no significant excess risk of PCI relative to CABG for stroke (HR, 0.85; 95% CI, 0.50 to 1.41; p = 0.52). In conclusion, there was no excess long-term mortality risk of PCI relative to CABG, while the excess risks of PCI relative to CABG were significant for myocardial infarction and any coronary revascularization in the present study population reflecting real-world clinical practice in Japan.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Incidencia , Japón/epidemiología , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Revascularización Miocárdica/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Sistema de Registros , Accidente Cerebrovascular/epidemiologíaRESUMEN
We report a case of pulmonary artery aneurysm and pulmonary stenosis with a quadricuspid pulmonary valve in a 64-year-old woman. While pulmonary artery disease had been found as a child, she needed no treatment because of the absence of symptoms and her normal physical development. She began experiencing dyspnoea on exertion 3 years ago. Echocardiography showed pulmonary artery aneurysm and severe pulmonary stenosis with a quadricuspid valve. Computed tomography showed a pulmonary artery aneurysm extending from its main trunk to the bilateral branches. The pulmonary valve was replaced, and the pulmonary trunk and its bilateral branch were reconstructed. The patient's postoperative course was uneventful.
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Hypertrophic obstructive cardiomyopathy in Libman-Sacks endocarditis is quite rare and the correct etiological relationship between them is unknown. Some changes may cause a secondary disorganization of the ordinary muscle structure, making a disarray pattern with irregular interwoven myocyte fibers. This case report describes one of the first cases of ventricular septal myectomy and mitral valve replacement for hypertrophic obstructive cardiomyopathy and mitral valve regurgitation associated with Libman-Sacks endocarditis.
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Cardiomiopatía Hipertrófica/etiología , Endocarditis/complicaciones , Insuficiencia de la Válvula Mitral/etiología , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Cardiomiopatía Hipertrófica/cirugía , Puente de Arteria Coronaria , Ecocardiografía , Endocarditis/diagnóstico por imagen , Endocarditis/cirugía , Femenino , Prótesis Valvulares Cardíacas , Humanos , Lupus Eritematoso Sistémico/complicaciones , Persona de Mediana Edad , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugíaRESUMEN
OBJECTIVE: Although surgical ventricular restoration for ischemic cardiomyopathy is expected as an alternative or bridge to heart transplantation, post-operative remodeling of left ventricle (LV) needs to be addressed. This study aimed to examine the effect of basic fibroblast growth factor (bFGF), which induces angiogenesis and tissue regeneration in ischemic myocardium, to prevent remodeling after surgical ventricular restoration (SVR) using a rat ischemic cardiomyopathy model. METHODS: Four weeks after coronary artery ligation, rats were divided into two groups: rats treated with SVR alone (SVR; n = 21), and rats treated with SVR and local sustained release of bFGF using gelatin hydrogel sheet (SVR + bFGF; n = 22). Cardiac function was assessed by serial echocardiography and cardiac catheterization. Cardiac tissue sections were histologically examined for vascular density and fibrosis. RESULTS: Higher systolic function and lower LV end-diastolic pressure (LVEDP) were observed in rats treated with SVR + bFGF (SVR vs SVR + bFGF; Ees: 0.22 ± 0.11 vs 0.33 ± 0.22 mmHg/µL, p = 0.0328; LVEDP: 12.7 ± 7.0 vs 8.5 ± 4.3 mmHg, p = 0.0230). LV area tended to be lower in rats treated with SVR + bFGF compared to rats treated with SVR alone (left-ventricular end-diastolic area: 0.66 ± 0.07 vs 0.62 ± 0.07 cm2, p = 0.071). Vascular density tended to be higher in rats treated with SVR + bFGF than those without bFGF (23.3 ± 8.1 vs 28.8 ± 9.5/mm2, p = 0.0509). CONCLUSIONS: BFGF induced angiogenesis and attenuated remodeling after SVR which secured the efficacy of SVR in a rat ischemic cardiomyopathy model.
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Cardiomiopatías/cirugía , Factor 2 de Crecimiento de Fibroblastos/farmacología , Ventrículos Cardíacos/efectos de los fármacos , Isquemia Miocárdica/cirugía , Remodelación Ventricular/efectos de los fármacos , Animales , Cateterismo Cardíaco , Procedimientos Quirúrgicos Cardíacos , Cardiomiopatías/tratamiento farmacológico , Diástole , Modelos Animales de Enfermedad , Ecocardiografía , Humanos , Hidrogeles/química , Masculino , Infarto del Miocardio/cirugía , Isquemia Miocárdica/tratamiento farmacológico , Neovascularización Patológica , Ratas , Ratas Sprague-Dawley , Proteínas Recombinantes/farmacología , RegeneraciónRESUMEN
AIMS: Tricuspid regurgitation (TR) has been reported to be associated with worse survival in various heart diseases, but there are few data in aortic stenosis (AS). METHODS AND RESULTS: In the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) Registry enrolling 3815 consecutive patients with severe AS, there were 628 patients with moderate or severe TR (TR group) and 3187 patients with no or mild TR (no TR group). The study patients were subdivided into the initial aortic valve replacement (AVR) stratum (n = 1197) and the conservative stratum (n = 2618) according to treatment strategy. The primary outcome measure was a composite of aortic valve-related death or hospitalization due to heart failure. The 5-year freedom rate from the primary outcome measure was significantly lower in the TR group than in the no TR group (49.1% vs. 67.3%, P < 0.001). Even after adjusting for confounders, the excess risk of TR relative to no TR for the primary outcome measure remained significant [hazard ratio (HR): 1.25, 95% confidence interval (CI): 1.06-1.48; P = 0.008]. The trend for the excess adjusted risk in the TR group was consistent in the initial AVR and the conservative strata (HR 1.55, 95% CI: 0.97-2.48; P = 0.07; HR 1.22, 95% CI: 1.02-1.46; P = 0.03, respectively). In the initial AVR stratum, the 5-year freedom rate from the primary outcome measure was not different between the two groups with (n = 56) or without (n = 91) concomitant tricuspid annuloplasty (61.5% vs. 72.1%, P = 0.48). CONCLUSION: The presence of clinically significant TR concomitant with severe AS is associated with a poor long-term outcome, regardless of the initial treatment strategy.
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Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/epidemiología , Implantación de Prótesis de Válvulas Cardíacas/métodos , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/epidemiología , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/fisiopatología , Estudios de Cohortes , Comorbilidad , Tratamiento Conservador/métodos , Ecocardiografía Doppler/métodos , Femenino , Humanos , Modelos Logísticos , Masculino , Análisis Multivariante , Pronóstico , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/fisiopatologíaRESUMEN
BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. MethodsâandâResults: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Espera Vigilante , Anciano , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/mortalidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Tasa de Supervivencia , Factores de Tiempo , Tiempo de TratamientoRESUMEN
We report a case of chronic dissecting thoracoabdominal aneurysm with intraoperative retrograde aortic dissection and rupture at proximal descending aorta, which was successfully treated by echoguided stent-graft insertion. An 82-year old male underwent thoracoabdominal aortic replacement for dilatation of infra-diaphragmatic aorta. Under F-F bypass, his thoracoabdominal aorta was replaced by a Dacron graft with 4-branches. After he weaned from F-F bypass, we found massive bleeding from proximal descending aorta. Trans-esophageal echocardiography (TEE) showed aortic dissection from the clamp site to the distal anastomotic site of the former total arch replacement. We temporary got hemostasis by suture and surgical glue, and anastomosed a 10 mm-graft to the thoracoabdominal main graft as conduit, then inserted and deployed 2 pieces of stent-graft. Direct echo and TEE contributed to the accurate positioning of them. Bleeding was completely controlled. He well recovered without paraplegia. Post-operative computed tomography (CT) showed good positioning and dilatation of the stentgraft and the perfect reverse remodeling of thoracic aorta.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Stents , Ultrasonografía Intervencional , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Aorta Torácica , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Rotura de la Aorta/diagnóstico por imagen , Ecocardiografía/métodos , Humanos , Masculino , Ultrasonografía Intervencional/métodosRESUMEN
OBJECTIVES: The aim of this study was to identify pathological changes of aortic dissection based on histopathological evaluation of aortic wall weakness by comparing patients with and without congenital abnormalities. METHODS: We reviewed records of patients who underwent repair for dissection-related aortic disease between 2008 and 2015. Fifty patients (20 men and 30 women; mean age 66.9 ± 14.0 years) who underwent surgery with subsequent histopathological examination of the aortic wall were divided into 2 groups. Group 1 had congenital abnormalities, including Marfan syndrome and bicuspid aortic valve (n = 5), and Group 2 had no congenital abnormalities (n = 45). We compared the histopathological characteristics of the aortic wall in these patients. RESULTS: There were significant differences in age and body surface area between the 2 groups. Although 80% of Group 1 patients developed dissection at the middle of the media, all Group 2 patients developed dissection at the outer one-third of the media, which is along the pathway of the vasa vasorum of the aortic wall. Both groups showed the same extent of degeneration of the vasa vasorum. Group 1 showed a severe score of mucoid extracellular matrix accumulation in the aortic media. CONCLUSIONS: Although it may be multifactorial, congenital maldevelopment of the media tends to result in dissection of the centre of the media, and acquired aortic wall weakness is concentrated in the outer third of the media. Degeneration of the vasa vasorum may be an important emerging substrate for developing aortic dissection.