Evaluation of novel indices of walking performance taking oxygen desaturation into account during six-minute walk test in cardiovascular disease patients.

In pulmonary disease patients since oxygen desaturation during 6-min walk test (6MWT) affects walk distance (6MWD), some novel indices such as desaturation/distance ratio [DDR, oxygen desaturation area (DAO2)/6MWD] and distance-saturation product [DSP, 6MWD × minimum peripheral oxygen saturation (SpO2)] are evaluated. However, there has been no study examining these indices that consider exercise-induced desaturation (EID) in patients with cardiovascular disease. In 94 cardiovascular disease patients without pulmonary complications, 6MWT and echocardiography were performed at the entry of cardiac rehabilitation. SpO2 was measured during 6MWT using a continuously monitorable pulse oximeter, and DSP and DDR were calculated using minimum SpO2 and DAO2 [sum of (100-SpO2) per second during 6MWT], respectively. EID was defined as SpO2 decrease of ≥ 4% or minimum SpO2 of < 90% during 6MWT. DSP was slightly lower and DDR was markedly higher in patients with EID than in those without. When examining correlations of DSP and DDR with their components, DSP was correlated with 6MWD much closely than minimum SpO2, while DDR was correlated as closely with DAO2 as 6MWD. Furthermore, DAO2, but not minimum SpO2, had a direct correlation with 6MWD. As for associations with cardiac function, DSP was correlated with several cardiac parameters, but DDR was not correlated with any of these parameters. Our findings suggest that oxygen desaturation during 6MWT affects walking distance in cardiovascular disease patients even without pulmonary complications and that DDR is more appropriate than DSP as an index of walking performance that takes EID into consideration, independently of cardiac function.

An automated screening model for aortic emergencies using convolutional neural networks and cropped computed tomography angiography images of the aorta.

PURPOSE: Patients with aortic emergencies, such as aortic dissection and rupture, are at risk of rapid deterioration, necessitating prompt diagnosis. This study introduces a novel automated screening model for computed tomography angiography (CTA) of patients with aortic emergencies, utilizing deep convolutional neural network (DCNN) algorithms. METHODS: Our model (Model A) initially predicted the positions of the aorta in the original axial CTA images and extracted the sections containing the aorta from these images. Subsequently, it predicted whether the cropped images showed aortic lesions. To compare the predictive performance of Model A in identifying aortic emergencies, we also developed Model B, which directly predicted the presence or absence of aortic lesions in the original images. Ultimately, these models categorized patients based on the presence or absence of aortic emergencies, as determined by the number of consecutive images expected to show the lesion. RESULTS: The models were trained with 216 CTA scans and tested with 220 CTA scans. Model A demonstrated a higher area under the curve (AUC) for patient-level classification of aortic emergencies than Model B (0.995; 95% confidence interval [CI], 0.990-1.000 vs. 0.972; 95% CI, 0.950-0.994, respectively; p = 0.013). Among patients with aortic emergencies, the AUC of Model A for patient-level classification of aortic emergencies involving the ascending aorta was 0.971 (95% CI, 0.931-1.000). CONCLUSION: The model utilizing DCNNs and cropped CTA images of the aorta effectively screened CTA scans of patients with aortic emergencies. This study would help develop a computer-aided triage system for CT scans, prioritizing the reading for patients requiring urgent care and ultimately promoting rapid responses to patients with aortic emergencies.

The E/e' ratio on echocardiography as an independent predictor of the improvement of left ventricular contraction in patients with heart failure with reduced ejection fraction.

OBJECTIVE: Clinical feature of heart failure with improved ejection fraction (HFimpEF) remains to be fully elucidated. The present study investigated the association of clinical and echocardiographic parameters with the subsequent improvement of left ventricular ejection fraction (LVEF) in heart failure with reduced ejection fraction (HFrEF). METHODS: From outpatients with a history of hospitalized for heart failure, 128 subjects diagnosed as HFrEF (LVEF <40%) on heart failure hospitalization were enrolled and longitudinally surveyed. During follow-up periods more than 1 year, 58 and 42 patients were identified as HFimpEF (improved LVEF to ≥40% and its increase of ≥10 points) and persistent HFrEF, respectively. RESULTS: There was no difference in age or sex between the two groups with HFimpEF and persistent HFrEF. The rate of ischemic heart disease was lower and that of tachyarrhythmia was higher in the HFimpEF group than in the persistent HFrEF group. At baseline (i.e., on heart failure hospitalization), LVEF did not differ between the two groups, but left ventricular systolic and diastolic diameters were already smaller and the ratio of early diastolic transmitral velocity to early diastolic tissue velocity (E/e') was lower in the HFimpEF group. A multiple logistic regression analysis revealed that lower baseline E/e' was a significant determinant of HFimpEF, independently of confounding factors such as ischemic heart disease, tachyarrhythmia, and baseline left ventricular dimension. CONCLUSION: Our findings indicate that the lower ratio of E/e' in the acute phase of heart failure onset is an independent predictor of the subsequent improvement of LVEF in HFrEF patients.

Renoprotective effect of chronic treatment with sodium-glucose cotransporter 2 inhibitors and its associated factors in Japanese patients with chronic heart failure and diabetes.

Background: Recent clinical trials have shown that sodium-glucose cotransporter 2 (SGLT2) inhibitors have beneficial effects on renal function in heart failure patients. This study confirmed the renoprotective effect of treatment with SGLT2 inhibitors in Japanese patients with chronic heart failure and diabetes and further investigated what cardiac/hemodynamic and noncardiac factors are involved in its effect. Methods: Eligible 50 outpatients with chronic heart failure and type-2 diabetes mellitus chronically taking SGLT2 inhibitors were enrolled. Annual changing rates of estimated glomerular filtration rate (eGFR) were compered before and after treatment with SGLT2 inhibitors and the associations of the change in eGFR slope after SGLT2 inhibitor administration with changes in various clinical and echocardiographic parameters were evaluated. Results: The mean follow-up periods before and after SGLT2 inhibitor administration were 2.6 and 1.9 years, respectively. Changing rates of eGFR per year were significantly improved after treatment with SGLT2 inhibitors (-5.78 ± 7.67 to -0.43 ± 10.81 mL/min/1.73 m2/year, p = 0.006). The daily doses of loop diuretics were not altered after SGLT2 inhibitor administration. Neither decreased body weight nor increased hematocrit was associated with the change in eGFR slope before and after SGLT2 inhibitor administration. While, the decrease in inferior vena cava diameter and the increase in its respiratory collapsibility were significantly correlated with the improvement of eGFR decline slope after SGLT2 inhibitor administration. Conclusions: Our findings indicated that chronic treatment with SGLT2 inhibitors ameliorated annual decline in eGFR in Japanese patients with chronic heart failure, suggesting the possibility that the improvement of venous congestion was involved in its renoprotective effect.

Cardiac metastasis of lung cancer presented as mimicking ST-elevation myocardial infarction with reciprocal electrocardiographic changes.

We report the case of a patient with metastatic cardiac tumor who presented with chest pain and electrocardiographic changes mimicking acute inferior myocardial infarction. An 84-year-old man who had undergone lung cancer surgery one year earlier was referred to emergency outpatient visit because of chest pain. His 12-lead electrocardiography (ECG) showed ST-segment elevation in the inferior leads with reciprocal ST-segment depression in the precordial and lateral leads, which was initially interpreted as inferior acute myocardial infarction. By emergency coronary angiography, however, there was no significant stenosis or occlusion in the right coronary artery or the left circumflex artery. In echocardiographic examinations after admission, a large mass was found in the area corresponding to the infero-posterior wall of the left ventricle, which had been detected only by positron emission tomography with computed tomography six months earlier. He died one month after admission. Pathological autopsy revealed a tumor of 8 × 5 cm size in the myocardium of the posterior to inferior wall of the left ventricle, and diagnosed as cardiac metastasis from lung cancer. ECG changes with ST-segment elevation, in particular persistent ST-elevation in the absence of Q waves, can be a sign for tumor invasion of the heart. Learning objective: It is necessary to consider the possibility of myocardial metastasis when a patient with malignancy presents with acute myocardial infarction-like electrocardiography findings. Besides, in this case, positron emission tomography with computed tomography (PET-CT) had detected an abnormal accumulation in the left ventricle earlier than when the tumor was pointed out by echocardiography. Multimodality imaging including PET-CT could help physicians to make the early and accurate diagnosis of metastatic cardiac tumor.

Achilles tendon thickness is associated with coronary lesion severity in acute coronary syndrome patients without familial hypercholesterolemia.

BACKGROUND: Thickening of Achilles tendon (≥9 mm on radiography) is one of the diagnostic criteria for familial hypercholesterolemia (FH). Since FH is associated with premature coronary artery disease (CAD) including acute coronary syndrome (ACS), measurement of Achilles tendon thickness (ATT) is important for early diagnosis of FH. However, clinical significance of mild thickening of Achilles tendon in non-FH patients with CAD is unclear. The present study investigated the association of ATT with coronary lesion severity in early-onset ACS without clinically diagnosed FH. METHODS: From outpatients who had a history of ACS under 60 years old, 76 clinically non-FH subjects (71 men and 5 women; mean age at the onset of ACS, 50.5 years) with maximum ATT of <9 mm were enrolled in this study. The severity of coronary lesions was assessed by SYNTAX score derived from coronary angiography at the onset of ACS. RESULTS: ATT levels were not significantly different among patients with ST-elevation myocardial infarction (STEMI, n=47), non-STEMI (n=12), and unstable angina (n=17). Whereas, both average and maximum ATT were significantly larger in patients with multivessel lesions (n=25) than in those with single-vessel disease (n=51). Furthermore, SYNTAX score was positively correlated with average ATT (r=0.368, p=0.0011) and maximum ATT (r=0.388, p=0.0005). As for the relation to clinical parameters, maximum ATT had positive correlations with body mass index and C-reactive protein. A multiple regression analysis revealed that average and maximum ATT were significantly associated with SYNTAX score, independently of various confounding factors. CONCLUSIONS: Our findings demonstrated that ATT, even though its level was <9 mm, was associated with coronary lesion severity in clinically non-FH patients with early-onset ACS. Apart from diagnosing FH, ATT may be a predictor of the progression of CAD.

Patient with penile metastasis from prostate cancer and survival over 5 years: A case report with longitudinal evaluation using computed tomography and magnetic resonance imaging.

Penile metastasis of malignant tumors is a very rare condition, often occurring as a part of systemic metastases, and is therefore associated with a poor prognosis. Although there have been reports of magnetic resonance imaging findings of penile metastasis, longitudinal imaging changes have not been presented previously. We report a case of a 80-year-old male patient with penile metastasis from prostate adenocarcinoma. First magnetic resonance imaging demonstrated multiple penile nodules in the left corpus cavernosum corpora cavernosa, and these nodules were fused and across the septum of the penis, forming an enlarged, diffusely spreading mass on the follow-up exam 5 years later. In this case, a longitudinal evaluation of magnetic resonance imaging demonstrated the course of the extension of the rare penile metastasis.

Long-term administration of tolvaptan ameliorates annual decline in estimated glomerular filtration rate in outpatients with chronic heart failure.

Protective effects of tolvaptan against worsening renal function in acute heart failure have been shown. However, long-term effects of its agent on renal function remain to be elucidated. The present study investigated retrospectively whether long-term treatment with tolvaptan exerts renoprotective effects in patients with chronic heart failure, by comparing serial changes in estimated glomerular filtration rate (eGFR) for years before and after tolvaptan administration. From 63 outpatients with chronic heart failure taking diuretics including tolvaptan, 34 patients whose eGFR levels were continuously measured for more than 6 months both before and after administration of tolvaptan (average dose, 7.8 mg/day at the end of the follow-up period) were selected as eligible for the present analyses. All eGFR values were separately plotted before and after the initiation of treatment with tolvaptan (except hospitalization periods) along the time course axis and the slope of the linear regression curve was calculated as an annual change in eGFR. The mean follow-up periods before and after tolvaptan administration were 1197 and 784 days (3.3 and 2.1 years), respectively. Changing rates of eGFR per year were significantly ameliorated after treatment with tolvaptan (mean ± SD, - 8.02 ± 9.35 to - 1.62 ± 5.09 mL/min/1.73m2 /year, P = 0.001). In echocardiographic parameters, inferior vena cava (IVC) diameter significantly decreased after tolvaptan administration, and the decrease in IVC diameter was correlated with the improvement of eGFR decline slope after administration of tolvaptan (P = 0.0075). This longitudinal observational study indicated that long-term treatment with tolvaptan ameliorated annual decline in eGFR in outpatients with chronic heart failure. Our findings suggest that tolvaptan has a protective effect against chronically worsening renal function in heart failure patients.

Chylothorax treated with targeted sclerotherapy by direct puncture of the lymphatic leakage site.

We report a novel application of targeted sclerotherapy to eradicate high-output chylothorax. The patient underwent thoracic duct embolization; however, cannulation of the thoracic duct failed, and thoracic duct disruption was performed. Leakage continued; therefore, the leakage site in the mediastinum was punctured directly under fluoroscopic guidance and a drainage catheter was inserted, followed by sclerotherapy using OK-432. Finally, leakage stopped and chylothorax improved. This technique may be useful for refractory chylothorax in patients where thoracic duct embolization fails.

[Extreme Obese Patients who Underwent Cardiac Surgery after Preoperative Weight Reduction;Report of Two Cases].

Obesity is a risk factor of postoperative complications. We experienced 2 extremely obese patients:a 32-year-old male with coronary artery disease and a 75-year-old female with aortic valve stenosis. Their initial body weights were 133 kg and 88.5 kg, respectively, and their initial body mass indexes (BMIs) were both 41. Their BMIs were reduced to 35.5 and 35, respectively, after preoperative weight reduction. Off-pump coronary artery bypass grafting and aortic valve replacement were performed, respectively. After surgery, the non-invasive positive pressure ventilation( NPPV) support was effective, and their postoperative courses were uneventful. Preoperative weight reduction and NPPV are useful for extremely obese patients who undergo cardiac surgery.

[Portal venous stent placement for variceal hemorrhage in the elevated jejunum caused by portal vein stenosis after pancreatoduodenectomy:a case report].

An 86-year-old male underwent pancreatoduodenectomy with resection and reconstruction of portal vein for pancreatic cancer. He was admitted to our hospital because of severe anemia and dyspnea ten months later. Computed tomography showed varices at the biliary-enteric anastomosis in the elevated jejunum caused by portal venous stenosis, which was suspected as the cause of anemia. Therefore, the patient underwent balloon dilatation of the portal vein followed by stent placement and coil embolization of the collaterals using a transileocolic portal vein approach. After the procedure, portal venous flow was improved, and the collaterals disappeared. The patient has been asymptomatic with no recurrence for three years and four months.

[A Case of Resection of Advanced Pancreatic Adenosquamous Carcinoma in which Multidisciplinary Treatment Was Effective].

A 72-year-old man with general fatigue was referred, and CT and MRI revealed a pancreatic mass with necrosis that was suspected of invading the stomach, splenic artery, celiac artery, liver, and portal vein. Upper gastrointestinal endoscopy showed an extrinsic mass with ulcer formation in the posterior wall of the upper gastric corpus and irregular mucosa in the lower esophagus incidentally. Biopsy showed squamous cell carcinoma from both lesions, leading to the diagnosis of pancreatic adenosquamous carcinoma and early esophageal cancer. We performed distal pancreatectomy with splenectomy, total gastrectomy, partial hepatectomy, superior mesenteric-portal vein resection, and reconstruction. The pathological results revealed pancreatic adenosquamous carcinoma and infiltration of cancer cells at the dissected peripancreatic margin. Therefore, we administered radiotherapy(50.4 Gy to the retroperitoneal region)in postoperative month 2. Endoscopic mucosal resection was performed for the early stage esophageal cancer lesion in postoperative month 5. Three courses of S-1 were administered as adjuvant therapy since postoperative month 7, and he is currently alive without recurrence 1 year and 8 months after surgery. Multidisciplinary treatment can be effective for locally advanced pancreatic adenosquamous carcinoma.

[A Case of Double Cancer of Intrahepatic Cholangiocarcinoma and Gastric Carcinoma with Difficult Diagnosis of the Primary Tumor with Peritoneal Metastasis].

Double cancer of intrahepatic cholangiocarcinoma and gastric cancer is rare. A 62-year-old man underwent gastrectomy for gastric cancer. The pathological findings were tub1>tub2, m, ly0, v0, n0, Stage I A. Two years and a month later, a liver tumor(diameter of 3 cm)and a pelvic mass(diameter of 2.5 cm)were observed. Metastasis from gastric cancer was suspected and chemotherapy(SOX)was administered. However, after 5 courses, CT revealed worseningof the liver tumor (diameter of 12 cm)and pelvic mass(diameter of 3 cm). Intrahepatic cholangiocarcinoma and its peritoneal metastasis were also suspected. There was a limit to treatment with chemotherapy, and it was difficult to judge whether to target gastric cancer or intrahepatic cholangiocarcinoma for chemotherapy. In addition, the lesions were localized in the right lobe of the liver and the pelvis. Therefore, we decided to perform resection. As a second-stage operation, pelvic mass extraction and portal vein embolization were performed first. The pathological result of the pelvic mass assessment was mucinous carcinoma. Subsequently, expansive right hepatectomy was performed. The pathological findings were also suggestive of mucinous carcinoma, which was finally diagnosed as intrahepatic cholangiocarcinoma and peritoneal dissemination. Six months after the surgery, several recurrent nodules were observed in the pelvis and GEM plus CDDP was initiated. Currently, 1 year after surgery, there are no restrictions in the activities of daily life of the patient and he is treated on an outpatient basis.

[Resection of Adrenal Metastasis after Chemotherapy and Radiation Therapy for a Patient with Stage IV B Hepatocellular Carcinoma].

In the treatment of hepatocellular carcinoma, atypical, off guideline multidisciplinary approaches are sometimes effective. A 70-year-old man was diagnosed with multiple hepatocellular carcinomas, multiple bone metastases, and a right adrenal metastasis. Sunitinib was started and the primary hepatic lesions and bone metastases disappeared. However, his adrenal metastasis worsened. Sorafenib, radiotherapy, and some investigational agents were administered, but the adrenal metastasis did not respond. There were no other new lesions except the adrenal lesion 4 years after the initial treatment, so we decided to perform a resection. In the left half lateral decubitus position, the adrenal mass was removed with right thoracolaparotomy. After the surgery, his tumor markers quickly returned to normal. Seven years after the initial treatment(2 years and 4 months after the last surgery), he is alive without any recurrence. Multidisciplinary treatment with chemotherapy, radiotherapy, and surgery may result in long term survival even for patients with advanced hepatocellular carcinoma with multiple extra-hepatic lesions.

Atresia of the right atrial ostium of the coronary sinus without persistent left superior vena cava.

We present a case of atresia of the right atrial ostium of the coronary sinus. Recognizing this anomaly is important during catheter ablation or cardiac surgery, which could be noninvasively evaluated by multidetector CT.

[Long Term Survival in a Case of Hilar Cholangiocarcinoma Treated with Chemotherapy and Surgery].

A 67-year-old man with elevated hepatobiliary enzymes was referred to our hospital for further examination. Computed tomography indicated hilar cholangiocarcinoma of Bismuth type Ⅳ and revealed invasion of the right hepatic artery and the left portal vein. We diagnosed locally advanced unresectable hilar cholangiocarcinoma, and performed 5 courses of chemotherapy with gemcitabine plus S-1. After chemotherapy, the tumor was significantly reduced in size and vascular invasions were alleviated, so we decided to perform surgical resection. An extended left hepatectomy with caudate lobe and extrahepatic bile duct resection was performed. Although the intraoperative pathological examination was positive for cancer at the hepatic margins, we did not perform further bile duct resection because of the difficulty. After the surgery, we administered adjuvant chemotherapy with gemcitabine for 5 courses. Another 8 courses of gemcitabine plus S-1 therapy were given because of elevation of CA19-9. The tumor marker levels normalized, and the patient is still alive without findings of recurrence 4 years after the first treatment. Multidisciplinary treatment with chemotherapy and surgery may suggest the possibility of increasing long term survival even for patients with locally advanced unresectable cholangiocarcinoma.

MR imaging of carcinosarcoma of the liver using Gd-EOB-DTPA.

We present a case of a 69-year-old man with primary hepatic carcinosarcoma who underwent computed tomography that revealed a hypervascular hepatic tumor with local dense calcification. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging revealed hyperintense lesions in the hepatobiliary phase that indicated hepatocellular carcinoma with bile production. The patient underwent right lobectomy, and the presence of a sarcoma component within the tumor on histopathology confirmed liver carcinosarcoma that included hepatocellular carcinoma. In cases with atypical images that resemble this case, the hyperintensity of a lesion in the hepatobiliary phase aids differential diagnosis.

[Mixed adenoneuroendocrine carcinoma with multiple liver metastases successfully treated by cetuximab/CPT-11 chemotherapy followed by curative resection - a case report].

A 73-year-old man underwent laparoscopy-assisted partial resection of the rectum to treat rectal cancer diagnosed in September 2011 at a previous hospital. Lymph node dissection was not performed and the vertical margin was positive. When multiple liver tumors were detected 10 months later, the patient was referred to our hospital. A computed tomography (CT) scan revealed local recurrence of the rectal cancer, lymph node metastasis, and 9 liver metastases, which had a maximum diameter of 10 cm, and where curative resection would have been difficult. The rectal cancer expressed epidermal growth factor receptor (EGFR) and wild type K-ras gene, and we initiated cetuximab/irinotecan (CPT-11) chemotherapy. After 2 courses of chemotherapy, the liver tumors had markedly decreased in size and anterior resection of the rectum with regional lymph node dissection was performed. The pathological diagnosis of the rectal tumor was mixed adenoneuroendocrine carcinoma ( MANEC). Extended right hepatectomy was performed four months later. The liver tumors were also diagnosed as metastases of MANEC of the rectum. The therapeutic efficacy of chemotherapy was assessed as Grade 1b. The patient is alive without recurrence 34 months since the initial rectal surgery and 15 months after the liver resection. Thus, an anti-EGFR antibody agent might be effective against MANEC of the colon and rectum.

Spontaneous rupture of the omental artery treated by transcatheter arterial embolization.

Intra-abdominal hemorrhage caused by omental artery rupture is a rare condition. There are few reports on the treatment of omental artery rupture with only transcatheter arterial embolization (TAE). A 27-year-old man presented to our emergency room with upper abdominal pain that suddenly occurred during sleep. Abdominal computed tomography (CT) revealed fluid collection in the peritoneal cavity and a left subphrenic hematoma with extravasation. Celiac angiography revealed extravasation from the omental artery, which arose from the proximal left gastroepiploic artery. A microcatheter was advanced into the left gastroepiploic artery and around the culprit artery bifurcation, which was embolized by inserting coils. The postoperative course was uneventful without worsening of anemia or abdominal symptoms. The patient was discharged after the absence of extravasation was confirmed by contrast-enhanced CT. Although surgical therapy has often been performed for omental bleeding, TAE, which is less invasive and has the advantage of simultaneous diagnosis and treatment, should be attempted as the first-choice therapy.