Surgical management of right hepatectomy after coronary artery bypass grafting using the right gastroepiploic artery: a case report and literature review.

BACKGROUND: Coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) is a well-established, safe procedure. However, problems with RGEA grafts in subsequent abdominal surgeries can lead to fatal complications. This report presents the first case of right hepatectomy for hepatocellular carcinoma after CABG using the RGEA. CASE PRESENTATION: We describe a case in which a right hepatectomy for an 81-year-old male patient with hepatocellular carcinoma was safely performed after CABG using a RGEA graft. Preoperatively, three-dimensional computed tomography (3D- CT) images were constructed to confirm the run of the RGEA graft. The operation was conducted with the standby of a cardiovascular surgeon if there was a problem with the RGEA graft. The RGEA graft had formed adhesions with the hepatic falciform ligament, necessitating meticulous dissection. After the right hepatectomy, the left hepatic lobe descended into the vacated space, exerting traction on the RGEA. However, this traction was mitigated by suturing the hepatic falciform ligament to the abdominal wall, ensuring stability of the RGEA. There were no intraoperative or postoperative complications. CONCLUSION: It is crucial to confirm the functionality and anatomy of the RGEA graft preoperatively, handle it gently intraoperatively, and collaborate with cardiovascular surgeons.

Ultrahigh-speed multiplex coherent anti-Stokes Raman scattering microspectroscopy using scanning elliptical focal spot.

We present a beam-scanning multiplex coherent anti-Stokes Raman scattering (CARS) microspectroscopy system using parallel excitation and parallel detection schemes based on an elliptical focal spot, which enables highly efficient signal acquisition even for short exposures. The elliptical focal spot was used to simultaneously observe the CARS signals of an enlarged region and reduce the peak irradiance. The developed system realized an acquisition rate of 34 139 spectra/s and enabled ultrahigh-speed acquisition of a vibrational spectroscopic image, covering the fingerprint region of 930-1 830 cm-1 with 256(x) × 256(y) × 512(spectrum) pixels in 1.92 s or with 128(x) × 128(y) × 256(spectrum) pixels in 0.54 s. We demonstrated ultrahigh-speed hyperspectral imaging of a mixture of polymer beads in liquid linoleic acid and living adipocytes using the developed system. All of the present demonstrations were performed with a low-peak irradiance excitation of ∼19 GW/cm2, which has been reported in previous studies to cause less photodamage to living cells. The label-free and ultrahigh-speed identification and visualization of various molecules made possible by the present system will accelerate the development of practical live-cell investigation.

Chronic Kidney Disease as a Possible Predictor of Left Atrial Thrombogenic Milieu Among Patients with Nonvalvular Atrial Fibrillation.

Patients with chronic kidney disease (CKD) experiencing atrial arrhythmia are hypothesized to have elevated CHADS2 and CHA2DS2-VASc scores, thereby predisposed to left atrial (LA) thrombus formation and subsequent thromboembolism. We examined possible association of LA thrombogenic milieu (TM) with CKD in patients with nonvalvular atrial fibrillation. A total of 581 patients (181 women; mean age, 67 years) who underwent transesophageal echocardiography were examined. Patients were divided into 4 groups based on the estimated glomerular filtration rate (eGFR) (ml/min/1.73 m2): eGFR ≥90 (n = 29), 60≤ eGFR <90 (n = 329), 30≤ eGFR <60 (n = 209), and eGFR <30 (n = 14). TM was defined as the presence of LA thrombus, dense spontaneous echo contrast, or LA appendage velocity ≤25 cm/s. Of 581 patients, 147 (25%) had TM. The prevalence of TM increased with decreasing eGFR (4%, 18%, 36%, and 86% for each group, p <0.001). Similar trends were observed for some of the clinical and echocardiographic variables including CHA2DS2-VASc score and LA size. Multivariate logistic regression analysis revealed that every 10 ml/min/1.73 m2 decrement in eGFR was a significant independent correlate of TM (odds ratio 0.80, p = 0.005), along with nonparoxysmal atrial fibrillation (AF) (odds ratio 0.45, p = 0.004), higher CHA2DS2-VASc score (odds ratio 1.24, p = 0.012), every 5 ml/m2 increment in LA volume index (odds ratio 1.57, p <0.001), and every 10% decrement in left ventricular ejection fraction (odds ratio 0.51, p <0.001). In conclusion, CKD may be a significant risk factor for LA thrombus formation in patients with nonvalvular atrial fibrillation.

Association between FGF23, α-Klotho, and Cardiac Abnormalities among Patients with Various Chronic Kidney Disease Stages.

BACKGROUND: Several experimental studies have demonstrated that fibroblast growth factor 23 (FGF23) may induce myocardial hypertrophy via pathways independent of α-Klotho, its co-factor in the induction of phosphaturia. On the other hand, few studies have clearly demonstrated the relationship between FGF23 level and left ventricular hypertrophy among subjects without chronic kidney disease (CKD; i.e., CKD stage G1 or G2). PURPOSE: To investigate the data from 903 patients admitted to the cardiology department with various degrees of renal function, including 234 patients with CKD stage G1/G2. METHODS AND RESULTS: Serum levels of full-length FGF23 and α-Klotho were determined by enzyme immunoassay. After adjustment for sex, age, and estimated glomerular filtration rate (eGFR), the highest FGF23 tertile was significantly associated with left ventricular hypertrophy among patients with CKD stage G1/G2 and those with CKD stage G3a/G3b/G4 as compared with the lowest FGF23 tertile, and the association retained significance after further adjustment for serum levels of corrected calcium, inorganic phosphate, and C-reactive protein, as well as diuretic use, history of hypertension, and systolic blood pressure. FGF23 was also associated with low left ventricular ejection fraction among patients with CKD stage G1/G2 and those with CKD stage G3a/G3b/G4 after adjusting for age, sex, eGFR, corrected calcium, and inorganic phosphate. On the other hand, compared with the highest α-Klotho tertile, the lowest α-Klotho tertile was associated with left ventricular hypertrophy and systolic dysfunction only among patients with CKD stage G3b and stage G3a, respectively. CONCLUSIONS: An association between FGF23 and cardiac hypertrophy and systolic dysfunction was observed among patients without CKD as well as those with CKD after multivariate adjustment. However, the association between α-Klotho and cardiac hypertrophy and systolic dysfunction was significant only among patients with CKD G3b and G3a, respectively.

Association between Left Ventricular Postsystolic Shortening and Diastolic Relaxation in Asymptomatic Patients with Systemic Hypertension.

BACKGROUND: Few data have existed on myocardial postsystolic shortening (PSS) accounting for left ventricular (LV) diastolic dysfunction in systemic hypertension. We examined this relationship, along with clinical and other cardiac parameters, in asymptomatic patients with hypertension. METHODS: We analyzed 104 patients on pharmacological treatment for hypertension who had no signs or symptoms of heart failure for conventional and speckle tracking echocardiography. The sum of the postsystolic index for multiple LV segments (total PSI) and global longitudinal strain (GLS) was computed and used as measures for global PSS and myocardial systolic function, respectively. The tissue Doppler e' and the speckle tracking-derived global strain rate during early diastole (e'sr) were obtained as indicators of LV relaxation. The circumferential end-systolic stress was also determined noninvasively and substituted for a measure of myocardial afterload. RESULTS: Main variables that correlated with the e' and e'sr were shown to be age, LV mass index, left atrial volume index, GLS, and the total PSI. Multivariate analysis including gender, circumferential end-systolic stress, and the use of calcium channel blockers as possible covariates revealed that age (ß = -0.29, P = 0.002), total PSI (ß = -0.26, P = 0.008), and LV mass index (ß = -0.25, P = 0.017) were significant independent determinants of e' and that age (ß = -0.34, P < 0.001) and GLS (ß = -0.28, P = 0.006) were of e'sr. CONCLUSIONS: Our findings indicate that while depending on the degree of GLS, PSS may affect diastolic relaxation in patients with asymptomatic, but treated, hypertensive patients.

Association between absolute blood eosinophil count and CKD stages among cardiac patients.

Elevated eosinophil count was shown to be associated with the development of cholesterol embolization syndrome, a potentially life-threatening condition, after catheter-based procedures. We investigated the association between stages of chronic kidney disease (CKD) and the absolute eosinophil count (AEC) among cardiac patients. CKD stages were determined solely on the estimated glomerular filtration rate or requirement for hemodialysis. Eosinophilia is defined as an eosinophil count exceeding 500/µL. A total of 1022 patients were enrolled in the current study, and eosinophil counts (/µL) in the first through fourth eosinophil count quartiles were <88, 88 to 154, 155 to <238, and 238 ≤, respectively, and 29 patients (2.8 %) had eosinophilia. Correlation coefficient between the AEC and age was -0.188 (P = 0.001) in women and -0.042 (n.s.) in men (by Spearman's correlation test). Patients with higher CKD stages had a higher prevalence of the highest AEC quartile or eosinophilia. Logistic regression analysis using severe renal dysfunction (i.e., CKD stage 4 or 5) as the dependent variable, the highest AEC quartile had a significant positive association with an odds ratio of 1.99 (95 % confidence interval, 1.20-3.31, P < 0.01) after adjustment for sex, age, systolic blood pressure, and total white blood cell count. Similarly, after adjustment for the same variables, eosinophilia was associated with severe renal dysfunction with an odds ratio of 2.60 (95 % confidence interval, 1.08-6.26, P < 0.05). Eosinophil count was positively associated with higher CKD stages among cardiology patients, some fraction of which might be related to subclinical cholesterol embolization.

Association between circulating FGF23, α-Klotho, and left ventricular diastolic dysfunction among patients with preserved ejection fraction.

Besides regulating calcium-phosphate metabolism, fibroblast growth factor-23 (FGF23) and Klotho have been proposed to have other roles in heart and vasculature. For example, FGF23 has been associated with cardiac hypertrophy and reduced left ventricular ejection fraction among patients with chronic kidney disease and cardiovascular disorders. The purpose of the study was to investigate whether serum FGF23 and α-Klotho concentrations are associated with cardiac diastolic dysfunction and related parameters among cardiac patients with preserved left ventricular ejection fraction. The current study enrolled 269 patients (69 women, 200 men) who were admitted to our cardiology department between October 2012 and January 2014 and had a left ventricular ejection fraction of >50%. Cardiac diastolic function was assessed by blood flow and tissue Doppler velocities, plasma B-type natriuretic peptide (BNP) concentration, and cardiac hypertrophy. After adjusting for sex, and age, logistic regression analysis showed that log(α-Klotho), but not log(FGF23), was significantly associated with diastolic dysfunction. After further adjustment for renal function, blood hemoglobin, and serum albumin levels, the negative association between log(α-Klotho) and diastolic dysfunction retained statistical significance with an odds ratio of 0.50 (95% confidence interval 0.31-0.81, P = 0.005, per 1 standard deviation). Among patients with preserved LVEF, serum α-Klotho concentrations were negatively associated with diastolic dysfunction. Whether modulation of serum levels α-Klotho will ameliorate cardiac diastolic function among patients with this disorder awaits further investigation.

Gender Specific Association between Serum Fibroblast Growth Factor 23/α-Klotho and Coronary Artery and Aortic Valve Calcification.

AIM: Fibroblast growth factor 23 (FGF23) and α-Klotho have been recently identified to play a crucial role in calcium/phosphate metabolism. We herein investigated the possible relation between serum FGF23/α-Klotho levels and coronary artery calcification (CAC) and aortic valve calcification (AVC). METHODS: Among subjects with diagnosed or suspected coronary artery disease (CAD), CAC and AVC were estimated via the Agatston score of 320-detector computed tomography images, and serum FGF23 and α-Klotho levels were measured. RESULTS: In total, 157 subjects were enrolled (75 women and 82 men). We performed logistic regression using CAC as a dependent variable; the highest FGF23 tertile (＞ 52.5 pg/mL) was significantly positively associated with CAC with an odds ratio of 6.61 versus the lowest FGF23 tertile (＜ 35.3 pg/mL) in women after the adjustment for potential confounding variables including age, renal function, hypertension, statin use, diuretic use, and calcium/phosphate metabolism related factors. In addition, the highest α-Klotho tertile (＞ 561 pg/mL) was significantly associated with AVC with an odds ratio of 6.31 versus the lowest α-Klotho tertile (＜ 306 pg/mL) in men after adjusting for the same variables. On the other hand, the association between FGF23 and CAC/AVC in men or that between α-Klotho and CAC/AVC in women was nonsignificant. CONCLUSION: Among subjects with diagnosed or suspected CAD, serum FGF23 was positively associated with CAC in women and serum α-Klotho was positively associated with AVC in men independent of the confounding variables, including the renal function and calcium/phosphate metabolism-related factors.

Serum uric acid is associated with cardiac diastolic dysfunction among women with preserved ejection fraction.

Serum uric acid (SUA) is associated with the severity and prognosis of systolic heart failure. We investigated the potential association between SUA and cardiac diastolic dysfunction among total of 744 cardiac patients (202 women and 542 men) who had preserved left ventricular ejection fraction. Presence of diastolic dysfunction was assessed by echocardiographic data, plasma B-type natriuretic peptide concentration, and left ventricular hypertrophy. Univariate analysis showed that the prevalence of diastolic dysfunction increased with increasing SUA value in women, but not in men. When sex-nonspecific SUA quartiles were used, multivariate logistic regression analysis, among female patients who were not taking uric acid lowering medication, showed that the third (SUA, 5.7-6.4 mg) and the fourth (SUA, ≥6.5 mg/dl) SUA quartiles were associated with diastolic dysfunction with an odds ratio of 3.25 (P < 0.05) and 8.06 (P < 0.001), respectively, when compared with the first SUA quartile (≤4.7 mg/dl). When sex-specific SUA quartiles were used among these population, multivariate logistic regression analysis showed that the fourth SUA quartile (≥5.7 mg/dl) was associated with diastolic dysfunction with an odds ratio of 5.34 (P < 0.05) when compared with the first SUA quartile (≤4.1 mg/dl). By contrast, the relationship between SUA and diastolic dysfunction was not significant in men, irrespective of which of the sex-nonspecific or sex-specific SUA quartiles were used. These data indicated that among cardiac patients with preserved ejection fraction, SUA was significantly associated with diastolic dysfunction in women but not in men.

Platelet volume indices are associated with systolic and diastolic cardiac dysfunction, and left ventricular hypertrophy.

BACKGROUND: Mean platelet volume (MPV) and platelet distribution width (PDW) are indices that reflect platelet activity. We investigated the association between these platelet indices and left ventricular hypertrophy and cardiac function. METHODS: We analyzed the data of 1241 patients who were admitted to the Cardiology Department. RESULTS: Both MPV and PDW were selected as independent factors associated with left ventricular systolic and diastolic dysfunction, and left ventricular hypertrophy. The highest tertile of MPV and PDW was associated with left ventricular systolic dysfunction (left ventricular ejection fraction of <50 %) with an odds ratio of 1.53 and 2.03, respectively, when the respective lowest tertile was used as reference. The highest PDW tertile was associated with left ventricular hypertrophy with an odds ratio of 1.56 (95 % CI, 1.13-2.15) and with dysfunction with an odds ratio of 3.34 (95 % CI, 1.54-7.25). CONCLUSIONS: Indices of platelet activation (MPV and/or PDW) were independently associated positively with left ventricular hypertrophy and left ventricular systolic and diastolic dysfunction. Whether these platelet indices represent useful markers for identifying individuals at higher risk for thromboembolic disease and organ damage among cardiac patients awaits further investigation.

Association of serum levels of FGF23 and α-Klotho with glomerular filtration rate and proteinuria among cardiac patients.

BACKGROUND: Expression and/or excretion of fibroblast growth factor-23 (FGF23) and its co-receptor Klotho are altered in patients with end-stage renal disease. The possibility that the FGF23/α-Klotho system mediates the aggravated cardiovascular outcome among patients with chronic kidney disease (CKD) has been suggested. We determined whether FGF23 and α-Klotho concentrations are altered among patients with reduced renal function and proteinuria. METHODS: Serum FGF23 and α-Klotho were measured in cardiology patients who were not undergoing chronic hemodialysis. Estimated glomerular filtration rate (eGFR) was correlated negatively with FGF23 and positively with α-Klotho. RESULTS: The correlation between FGF23 and the renal tubular maximum reabsorption rate of phosphate to the GFR (TmP/GFR) was not significant, but that between FGF23 and serum calcium or inorganic phosphate was significant among patients with an estimated GFR of less than 60 mL/min/m(2). By stepwise multivariate regression analysis, eGFR was selected as significant predictor for FGF23 or α-Klotho among patients with an estimated GFR of less than 60 mL/min/m(2); however, urine albumin/creatinine ratio was not selected as a predictor for FGF23 or α-Klotho irrespective of the eGFR levels. In patients with eGFR of <60 mL/min/1.73 m(2), UACR was significantly associated with log(FGF23); but, this association did not remain statistically significant in a multivariate model. CONCLUSIONS: Among cardiology patients with various stages of CKD, serum concentrations of FGF23 and α-Klotho were associated with renal function, but not with the extent of proteinuria.

Left ventricular mechanical discoordination in nonischemic hearts: relationship with left ventricular function, geometry, and electrical dyssynchrony.

BACKGROUND: Mechanical discoordination (MD) is known as a myocardial deformation of opposite strain during ejection, reflecting dyssynchronous electrical activation. We used speckle tracking echocardiography to examine the relationship between MD, left ventricular (LV) function and geometry, as well as electrical dyssynchrony in various nonischemic hearts. METHODS AND RESULTS: We examined 131 subjects (left bundle branch block [LBBB] 27; dilated cardiomyopathy [DCM] without LBBB 33; LV hypertrophy 28; and normal heart 43) using circumferential strain rate analysis. Integration of positive (stretch) and negative (shortening) components during the ejection time was obtained in the mid-ventricular level for 6 myocardial segments, and MD was quantified as the stretch to shortening ratio (SSR). The SSR in the septal region (anteroseptal and septal segments) was markedly elevated in the LBBB and DCM groups compared with the other groups. With univariate analysis, SSR over the septal region was found to be correlated with QRS duration, LV end-diastolic dimension, and LV ejection fraction. Multivariate analysis revealed that QRS duration and LV ejection fraction were significant independent determinants of SSR for the septal region. CONCLUSIONS: In nonischemic hearts, electrical dyssynchrony and LV dysfunction may contribute synergistically to MD in the septal region. The finding that non-LBBB DCM patients exhibited a certain amount of SSR may provide new insight into therapeutic strategies for cardiac resynchronization therapy.

Association between presystolic ventricular flash and left ventricular functional recovery after cardiac resynchronization therapy.

The presence of septal flash (SF), an early inward/outward motion of the ventricular septum, has been reported to predict a fair response to cardiac resynchronization therapy (CRT) in patients with heart failure. Using speckle tracking echocardiography, we investigated whether the extent of pre-CRT SF was associated with left ventricular (LV) functional recovery after CRT device implantation. Fifteen patients with left bundle branch block with a mean LV ejection fraction of 23 ± 9% were enrolled in this study. The extent of presystolic ventricular flash (PSVF), which was defined if there was a peak in the radial strain curve in the preejection period, was semiquantified by counting the number of PSVF-positive segments. Patients underwent radial strain analysis before and between 3 and 6 months after CRT. After CRT device implantation, LV end-diastolic and end-systolic volumes were decreased, LV ejection fraction was increased, and LV filling time corrected by RR interval was increased. The number of PSVF-positive segments at baseline showed a graded association with improvement in both LV ejection fraction and LV filling time. In conclusion, the finding that a larger number of PSVF-positive segments before CRT predicted fair LV functional recovery after CRT suggests that PSVF may represent a substrate that is amenable to functional response to CRT.

Association between serum immunoglobulin G4 concentration and cardiac function among elderly cardiology inpatients.

AIM: To study whether there is an association between serum immunoglobulin G4 (IgG4) concentration and cardiac function among cardiology inpatients. METHODS: This retrospective study included 91 patients who had sinus rhythm. Of 91 patients, 70 patients (77%) were aged ≥ 60 years (elderly group) and the remaining 21 patients (23%) were aged <60 years (younger group). RESULTS: Serum IgG4 concentrations were found to be negatively correlated with brain natriuretic peptide (BNP) and with E/e', an indicator for cardiac diastolic function in the elderly group, but not in the younger group. In contrast, IgG4 was significantly correlated with neither left ventricular mass nor ejection fraction in either group. Multivariate regression analysis showed that, in the elderly group, the association between IgG4 and E/e', and that between IgG4 and BNP, were independent of age, sex, systolic blood pressure and renal function; log-transformed IgG4 showed a negative association with log-transformed E/e' and log-transformed BNP, with a standardized correlation coefficient of -0.26 (95% confidence interval -0.49 to -0.03, P = 0.030 and -0.22 (95% confidence interval -0.44 to -0.11, P = 0.043), respectively. CONCLUSION: Serum IgG4 concentration might be associated with cardiac diastolic function among elderly cardiology inpatients.

Sarcoidosis does not belong to or overlap with immunoglobulin G4-related diseases based on an assessment of serum immunoglobulin G4 levels in cardiac and noncardiac sarcoidosis.

Although sarcoidosis may exhibit histopathologic features similar to those of a newly emerging clinical entity, immunoglobulin G4-related sclerosing disease, sarcoidosis is currently not considered to be associated with immunoglobulin G4-related immunoinflammation. Not many studies on this association have been reported. We investigated serum immunoglobulin G4 levels among patients with sarcoidosis with or without cardiac involvement (cardiac sarcoidosis and non-cardiac sarcoidosis patients). The mean serum immunoglobulin G4 level among the 65 patients with sarcoidosis was 56.8 ± 43.0 mg/dL, which did not significantly differ between patients with cardiac sarcoidosis (54 ± 48 mg/dL, n = 12) and patients without cardiac sarcoidosis (58 ± 42 mg/dL; n = 53). Serum level of soluble interleukin 2 receptor, a potent marker that may reflect sarcoidosis activity, was elevated in cardiac sarcoidosis (910 ± 683 U/L) and noncardiac sarcoidosis (689 ± 399 U/L) but did not significantly differ between the groups. Immunohistochemistry of cardiac or lymph node specimens from patients with cardiac sarcoidosis showed only sparse or no infiltration of immunoglobulin G4-positive lymphocytes, in contrast to the moderate to severe infiltration of CD68-positive macrophages and CD45-positive lymphocytes. Although the number of study subjects was small, these findings collectively suggest that regardless of the presence or absence of cardiac involvement, sarcoidosis does not belong to or overlap with immunoglobulin G4-related sclerosing disease.