Prognostic significance of baseline low-density lipoprotein cholesterol in patients undergoing coronary revascularization; a report from the CREDO-Kyoto registry.

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 (<85 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: 19.4 %, low: 14.5 %, intermediate: 11.1 %, high: 10.0 %, and very high: 9.2 %; p < 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, 95 % CI 1.16-1.44, p < 0.001; low: HR 1.15, 95 % CI 1.03-1.29, p = 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, 95 % CI 1.01-1.35), non-cardiovascular death (HR 1.35, 95 % CI 1.15-1.60), sudden death (HR 1.44, 95 % CI 1.01-2.06), and heart failure admission (HR 1.11 95 % 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.

Modifiers of the Risk of Diabetes for Long-Term Outcomes After Coronary Revascularization: CREDO-Kyoto PCI/CABG Registry.

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.

Percutaneous coronary intervention using new-generation drug-eluting stents versus coronary arterial bypass grafting in stable patients with multi-vessel coronary artery disease: From the CREDO-Kyoto PCI/CABG registry Cohort-3.

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.

Coronary Revascularization in the Past Two Decades in Japan (From the CREDO-Kyoto PCI/CABG Registries Cohort-1, -2, and -3).

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) (n = 20,106), or isolated coronary artery bypass grafting (CABG) (n = 4,845) using the data in a series of the CREDO-Kyoto PCI/CABG Registries (Cohort-1 [2000 to 2002]: n = 7,435, Cohort-2 [2005 to 2007]: n = 8,435, and Cohort-3 [2011 to 2013]: n = 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%, p = 0.74), while cardiovascular death decreased over time (5.7%, 5.1%, and 4.8%, p = 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, p = 0.03, and HR:0.80, 95%CI:0.70 to 0.92, p = 0.002, respectively), and from Cohort-2 to Cohort-3 (HR:0.86, 95%CI:0.78 to 0.95, p = 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.

Successful surgical transmitral removal of left ventricular thrombus after acute anterior myocardial infarction without left ventriculotomy.

Left ventricular thrombus (LVT) is known as a life-threatening complication of acute myocardial infarction, in terms of sequential systemic embolization. When an LVT is found to be sufficiently large or mobile, not only anticoagulation therapy but also surgical thrombectomy should be administered immediately to prevent embolic events. Generally, since infarcted myocardium is comparatively fragile, ventriculotomy may result in anastomotic failure or further deterioration of LV function. We report herein a case of transmitral removal of LVT by which we successfully avoided ventriculotomy. A 50-year-old Japanese man was hospitalized due to ST-segment elevation myocardial infarction and emergency coronary angiography revealed total occlusion at the proximal left anterior descending artery. On hospital day 9, transthoracic echocardiography detected a massive LVT at the apex, protruding into the left ventricle. Considering the risk of embolization, urgent thrombectomy via a transmitral approach was performed. The LVT was easily removed through the mitral valve under endoscopic support, without any embolic events or postoperative complications. .

Comparison of Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Among Patients With Three-Vessel Coronary Artery Disease in the New-Generation Drug-Eluting Stents Era (From CREDO-Kyoto PCI/CABG Registry Cohort-3).

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.

Successful Treatment of Cardiac Tamponade due to Rupture of the Heart Performing an Open-chest Pericardiotomy.

A 78-year-old woman with mild dementia was found unconscious by her family. She was transported by an ambulance to our emergency room (ER). Initially, she was comatose and in a state of shock. The echocardiographic findings suggested cardiac tamponade by hematoma. Computed tomography also showed tamponade without aortic dissection. After imaging, she went into cardiac arrest, was returned to the ER, and tracheal intubation and left thoracotomy for pericardiotomy were performed. A return of spontaneous circulation was obtained by following this procedure. Bleeding from a rupture of the left cardiac free wall was confirmed, and the rupture was closed with TachoSil®. After closing the thoracotomy, electrocardiography revealed ST elevation in the precordial leads. Subsequently, placement of an indwelling intra-aortic balloon pump and coronary angiography (CAG) were performed. CAG showed an occlusion of the anterior interventricular branch and circumflex branch of the left coronary artery. She underwent conservative therapy in a coronary care unit. Finally, after obtaining hemodynamic stability and baseline mental status, she was transferred to another medical facility. We herein report a rare case involving the successful treatment of cardiac tamponade due to rupture of the heart performing an open-chest pericardiotomy and additionally discuss the key points for obtaining a favorable outcome.

AORTIC INJURY DUE TO PARAGLIDING: A CASE REPORT.

A 64-year-old male fell from an altitude of 10 m while paragliding after stalling due to the wind. The purpose of this case report is to describe the outcomes after multiple injuries sustained during a paragliding accident, including a potentially life-threating injury to the thoracic aorta. The subject sustained a bite wound on his tongue, injuries to his chest (left side) and back, and a right forearm deformity. Enhanced whole body computed tomography (CT) revealed fractures of the bilateral laminae of the second and third cervical bones, right first rib, the tenth thoracic vertebral body (compression type), second lumbar vertebral body (burst type) and the right radius, Other injuries included an injury to the thoracic aortic arch and the presence of intraabdominal fluid collection without perforation of the digestive tract. Endovascular treatment was selected for the aortic injury because of multiple injuries. Immediate management included hypotensive rate control therapy using calcium and a beta blocker. On the fourth hospital day, the subject underwent deployment of a stent-graft to the aorta and subsequent surgical immobilization for the lumbar burst fracture. He also underwent surgical immobilization of the radial fracture and was discharged on the 28th hospital day. First responders or physicians should consider the possibility of aortic injury when treating patients who suffer falls while paragliding and provide appropriate management. Failure to provide appropriate management of an aortic injury could result in death. LEVEL OF EVIDENCE: 4.

Factors for sac size change of abdominal aortic aneurysm after endovascular repair.

OBJECTIVES: Factor(s) affecting the sac size of an abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) remain unclear. We compared the diameter of the aneurysm sac at one year after surgery with the preoperative diameter using CT images. METHODS: Patients who underwent EVAR at Juntendo University Hospital were involved. According to the size change in treated lesions of the aorta, patients were categorized into the following 3 groups: shrink (<5 mm of reduction), enlarge (>5 mm of expansion), and no change (size change within 5 mm). The patients' background, laboratory data, devices used, medications, anatomical characteristics, and presence/absence of postoperative endoleaks were examined. RESULTS: Of the 68 consecutive patients, 23 were excluded. Seventeen patients were classified into the shrink group, 28 patients into the no change group, and no patients into the enlarge group. Patients with higher thrombotic area rate on the preoperative AAA tended to present AAA sac shrinkage (p = 0.05). No other variables affected the size change in this study. In addition, the existence of an endoleak suggested the interference of sac shrinkage. CONCLUSIONS: The higher AAA thrombotic area rate tended to associate with AAA sac shrinkage.

Safety advantage of modified minimally invasive cardiac surgery for pediatric patients.

Minimally invasive cardiac surgery (MICS) using a small surgical incision in children provides less physical stress. However, concern about safety due to the small surgical field has been noted. Recently, the authors developed a modified MICS procedure to extend the surgical field. This report assesses the safety and benefit of this modified procedure by comparing three procedures: the modified MICS (group A), conventional MICS (group B), and traditional open heart surgery (group C). A retrospective analysis was performed with 111 pediatric patients (age, 0-9 years; weight, 5-30 kg) who underwent cardiac surgery for simple cardiac anomaly during the period 1996-2010 at Juntendo University Hospital. The modified MICS method to extend the surgical view has been performed since 2004. A skin incision within 5 cm was made below the nipple line, and the surgical field was easily moved by pulling up or down using a suture or a hemostat. The results showed no differences in terms of gender, age, weight, or aortic cross-clamp time among the groups. Analysis of variance (ANOVA) indicated significant differences in mean time before cardiopulmonary bypass (CPB), CPB time, operation time, and bleeding. According to the indices, modified MICS was similar to traditional open surgery and shorter time or lower bleeding volume than conventional MICS. No major mortality or morbidity occurred. In conclusion, the modified MICS procedure, which requires no special techniques, was as safe as conventional open heart surgery and even reduced perioperative morbidity.

Aortic valve replacement to a patient with high titer of cold agglutinin.

A 60-year-old man was admitted to our hospital because of aortic stenosis with a peak pressure gradient of 61 mmHg, moderate aortic regurgitation, and a dilatation of the ascending aorta of 50 mm in diameter, which had grown 5 mm in 2 years. Because of severe aortic stenosis with a bicuspid valve and fast progression of the ascending aorta in size, replacements of both the aortic valve and the ascending aorta were planned.He had experienced severe acute renal failure with hemolysis because of cold agglutinin one year before the operation. The hemoglobin had decreased to 4.3 g/dL during hemolytic attack. His titer of cold agglutinin was extremely high. The titer of cold agglutinin has kept above than 1:131072 at 4 degree Celsius. It once increased to 1:524288.Both the replacement of the aortic valve and the ascending aorta under normothermic cardiopulmonary bypass using intermittent warm blood cardioplegia were completed uneventfully. He was discharged from the hospital on postoperative day 11.

Comparing outcomes after off-pump coronary artery bypass versus drug-eluting stent in diabetic patients.

BACKGROUND: Off-pump coronary artery bypass surgery and sirolimus-eluting stent placement have been widely used for the treatment of coronary artery disease. The goal of this study was to compare long-term outcomes after off-pump coronary artery bypass surgery or sirolimus-eluting stent placement in diabetic patients with multivessel disease. METHODS: This observational study enrolled 350 off-pump coronary artery bypass patients and 143 sirolimus-eluting stent patients receiving care at our institution between 2000 and 2007. All patients had diabetes and multivessel disease including proximal left anterior descending or left main coronary artery. The choice of revascularization (percutaneous coronary intervention versus coronary artery bypass surgery) was left to the physician's discretion rather than randomization. Cox proportional-hazard analyses, adjusting baseline risk factors and propensity score, which predicted the probability of receiving off-pump coronary artery bypass, were conducted to evaluate outcomes, including all-cause mortality, cardiac death, target vessel revascularization, and major adverse cardiac and cerebrovascular events. RESULTS: During the follow-up (2.6±1.6 years) period, there was no difference between off-pump coronary artery bypass and sirolimus-eluting stent placement in all-cause mortality or cardiac death. However, the incidences of acute coronary syndrome, target vessel revascularization, and major adverse cardiac and cerebrovascular events were markedly lower in the patients undergoing off-pump coronary artery bypass than in those receiving sirolimus-eluting stent placement. CONCLUSION: Off-pump coronary artery bypass is superior to sirolimus-eluting stent placement in terms of acute coronary syndrome, target vessel revascularization, and major adverse cardiac and cerebrovascular events in diabetic patients with multivessel coronary artery disease.

Mid-term results for the Maze procedure in patients with non-mitral valvular atrial fibrillation.

BACKGROUND: The Maze procedure in patients without mitral valve disease remains controversial, because of the increased invasiveness and operation time required to create additional incisions in the atria. The aim of this study was to assess prognosis following the Maze procedure in patients without mitral valve disease. METHODS AND RESULTS: One hundred and seven consecutive patients who underwent the Maze procedure between 2002 and 2008 was enrolled in this study. Patients were divided into two groups based on the presence or absence of mitral valve disease. Freedom from atrial fibrillation was compared by multivariate logistic regression analysis at discharge. The Kaplan-Meier method and Cox-proportional hazard analysis adjusted for other predictors were estimated to compare freedom from atrial fibrillation at follow-up. Follow-up was 98% complete and mean duration of follow-up was 457 days. Operation and aorta cross-clamp times were similar between groups. No differences were identified in freedom from atrial fibrillation at discharge (non-mitral valve surgery, 55% vs. mitral valve surgery, 66%) or follow-up (57% vs. 61%, respectively). In multivariate Cox proportional hazard modelling, the presence of mitral valve disease was not associated with a poor success rate of conversion. CONCLUSIONS: Results of the Maze procedure for atrial fibrillation without mitral valve disease were acceptable. The Maze procedure could be a beneficial option for these patients to avoid adverse events of atrial fibrillation.

Effect of preoperative hemoglobin A1c levels on long-term outcomes for diabetic patients after off-pump coronary artery bypass grafting.

BACKGROUND: Diabetes mellitus is an independent risk factor for cardiovascular events after coronary artery bypass grafting (CABG), and hemoglobin A1c (HbA1c) is the most convenient marker for monitoring glycemic control among diabetic patients. However, few studies have reported the impact of baseline HbA1c levels on outcomes for diabetic patients after CABG. This study therefore aimed to investigate whether preoperative HbA1c levels in diabetic patients are predictive of long-term outcomes after off-pump CABG (OPCAB). METHODS AND RESULTS: Of 893 patients undergoing primary isolated OPCAB at Juntendo University Hospital from July 2002 to December 2007, subjects comprised 306 diabetic patients <80 years old. We divided these patients into 3 groups according to the preoperative HbA1c levels. No significant differences in baseline characteristics, angiographic findings, or operative parameters were apparent among the 3 groups. No operative or in-hospital mortality occurred. All-cause mortality and cardiac mortality rates were 6.2% (19 cases) and 1.3% (4 cases), respectively. Kaplan-Meier's survival showed no significant differences in all-cause or cardiac mortality (log-rank test, p=0.26, p=0.17, respectively). Multivariate analysis by Cox's proportional hazards model also demonstrated that no covariates predicted mortality except for age. CONCLUSIONS: Preoperative HbA1c levels might not predict long-term outcomes for diabetic patients undergoing OPCAB. Careful evaluation for diabetes should be needed in preoperative management of CABG.

Echocardiographic assessment of the effects of mitral valve repair on mitral valve geometry in rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: While mitral valve replacement is generally considered as the standard surgical treatment for rheumatic mitral stenosis (MS), mitral valve repair may be an alternative therapeutic option. Several techniques have been used to overcome the anatomic difficulties involved in the repair of a rheumatic mitral valve. In the present study, quantitative echocardiography was used to investigate the effects of mitral valve repair and the influence of surgical procedures on mitral valve geometry in patients with rheumatic MS. METHODS: Mitral valve repair was successfully performed in seven patients with MS, by the same surgeon. Ring annuloplasty and slicing of the anterior mitral leaflet (AML) were performed in all patients. Concomitant surgical techniques included commissurotomy, decalcification, chordal resection, and division of the papillary muscles. The preoperative and postoperative echocardiographic findings in these patients were compared. RESULTS: The thickness of both the AML and posterior mitral leaflet (PML) (p = 0.01 for both), the opening angles of the AML (p = 0.02) and PML (p = 0.01), and the closing angle of the PML, the extent of calcification in the AML, and the pressure half-time (PHT) (p = 0.03 for all three parameters) were all significantly improved after mitral valve repair. CONCLUSION: In the present study, the transmitral peak velocity and mean pressure gradient were not significantly changed after mitral valve repair, whereas the PHT showed a marked improvement. Hence, the PHT may represent a suitable marker for evaluating the efficacy of mitral valve repair for MS.

The role of EuroSCORE in patients undergoing off-pump coronary artery bypass.

INTRODUCTION: European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used to predict the postoperative mortality rate for patients undergoing open-heart surgery. The contributions of EuroSCORE in off-pump coronary artery bypass grafting (CABG) has not yet clearly elucidated. METHODS: Consecutive patients of isolated off-pump CABG performed from 2000 when we start performing 'routine' off-pump procedures were stratified using the additive EuroSCORE. Incidence of postoperative mortality, morbidity, and recovery were assessed, and compared to an historical cohort of on-pump procedures performed between 1991 until 1998 when CABG had been routinely performed under on-pump. RESULTS: There were 1318 patients in the off-pump and 1162 patients in the on-pump group. EuroSCORE of the off-pump group was significantly higher than that of the on-pump group. In both the on- and off-pump groups, mortality, total incidence of major complications, heart failure, and renal failure, and three parameters of recovery time were well correlated with EuroSCORE; however, the discriminatory power of the EuroSCORE model was always better in the on-pump group than in the off-pump group. Stroke was correlated with EuroSCORE only in the on-pump group. Pneumonia, mediastinitis postoperative myocardial infarction, or mediastinitis was not correlated with EuroSCORE in either group. In the off-pump group, postoperative major complication was reduced and postoperative recovery was shortened significantly, compared to those in the on-pump group. CONCLUSION: In off-pump CABG, EuroSCORE can, but not as good as in on-pump CABG, predict mortality, certain major postoperative complications, and postoperative recovery. This suggests off-pump technique appears to modify the risk stratification of the patients undergoing CABG.

The Use of Enclose(®)II Anastomosis Assist Device for the Proximal Coronary Branch Anastomosis to Vascular Graft.

We used the Enclose(®)II anastomosis assist device (Novare Surgical Systems, Inc., CA, USA), which was originally developed as an ancillary device for proximal anastomosis in off-pump coronary artery bypass grafting (OPCAB), to assist anastomosis for the vascular grafts without clamping those conduits in two cases. In these cases, it was difficult to clump vascular graft partially, because vascular graft was short. So we used Enclose(®)II anastomosis assist device for these cases. The advantage of this method is that the Enclose(®)II anastomosis assist device facilitates the anastomosis of arterial side branches to the artificial graft (1) by eliminating the use of partial clamp on the artificial conduits and (2) by providing a plane surface for easy handling for suture.

Reconsiderations of mitral stenosis: rheumatic mitral valve repair and the Wilkins score.

BACKGROUND: Mitral valve repair is a feasible treatment option in patients with rheumatic mitral valve disease, but it is not always successful. Mitral valve replacement is generally the surgical treatment of choice in such patients. We aimed to examine whether the Wilkins score can predict the feasibility of surgical repair in such patients. METHODS: Mitral valve surgery was performed on 14 patients by the same surgeon (A.A.). Five patients underwent mitral valve repair (group I), and nine patients underwent mitral valve replacement (group II). The Wilkins scores were determined by assessing echocardiography findings. The selection of mitral valve repair or replacement was based on the intraoperative findings and the preferences of the same surgeon (A.A.). In group I, we performed chordal reconstruction, augmentation of the posterior leaflet, resection of chordae, decalcification of the commissure, commissurotomy, slicing of the anterior leaflet, division of the papillary muscle, and ring annuloplasty in various combinations. RESULTS: There were no significant differences between the two groups with regard to any component of the preoperative Wilkins score. There was no significant difference in the pre- and postoperative scores in group I; however, the mitral valve orifice area was significantly improved after the operation (pre- and postoperative mean values: 1.3 ± 0.3 and 2.0 ± 0.4, P < 0.05). CONCLUSION: Mitral valve repair is effective in treating rheumatic mitral stenosis. However, the Wilkins score may not be useful in predicting the feasibility of mitral repair.

Controlled release of matrix metalloproteinase-1 plasmid DNA prevents left ventricular remodeling in chronic myocardial infarction of rats.

BACKGROUND: The present study investigated whether administration of controlled release matrix metalloproteinase-1 (MMP-1) plasmid DNA prevents left ventricular (LV) remodeling in a rat chronic myocardial infarction (MI) model. METHODS AND RESULTS: Rats with a moderate-sized MI were randomized to 2 groups: injection of phosphate buffered saline (PBS) containing microspheres into the peri-infarct area (MI group, n=14) and injection of cationized gelatin microspheres incorporating MMP-1 plasmid DNA (MI+MMP-1 group, 50 microg MMP-1/20 microl; n=14). As a control group (n=14), rats received neither the coronary artery ligation nor the injection of PBS. Echocardiography, cardiac catheterization and histological studies were performed. At 2 and 4 weeks after the treatment, the MI+MMP-1 group had smaller LV end-diastolic and end-systolic dimensions, better fractional area change and smaller akinetic areas than the MI group. The LV end-systolic elastance and time constant of isovolumic relaxation were also better in the MI+MMP-1 group compared with the MI group 4 weeks after the treatment. Fibrosis evaluated with Masson's trichrome staining was less in the MI+MMP-1 group than the MI group. CONCLUSIONS: Gelatin microspheres for the controlled release of MMP-1 plasmid DNA are promising for improving cardiac remodeling and function when they are administered during the chronic phase of MI.