Photostability evaluation of manidipine tablets and structural determination of its photoproducts.

Manidipine (MP) is a dihydropyridine drug, which is treated for the reduction of high blood pressure. The aim of this study is to clarify the photochemical behavior of MP in the case of ultraviolet light (UV) irradiation for MP tablets (Calslot® tablets). The tablets and its altered forms (powders and suspensions) were UV-irradiated using a black light, and residual amounts of active pharmaceutical ingredients (APIs) were monitored by high-performance liquid chromatography (HPLC). Due to the photoproducts of MP were detected in HPLC chromatograms, the elucidation of their chemical structures was carried out utilizing electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS). As a result, APIs in Calslot® tablets were almost completely photodegraded in the case that Calslot® tablets were suspended in an aqueous media along with the generation of some MP photoproducts. LC-ESI-MS/MS analysis clarified the chemical structures of three MP photoproducts, indicating that they were a pyridine analogue, benzophenone and a hydrolysate. Benzophenone was a main MP photoproduct. It was possible that MP might be firstly oxidized to form its pyridine analogue, followed by the oxidation of a dimethyl methylene moiety. This moiety seemed to be eliminated as a benzophenone, and the cleavage of an ester bond of the residual moiety resulted in the generation of a hydrolysate. Finally, toxicological potencies of MP and its photoproducts were predicted in silico toxicity evaluation, suggesting some of biological effects of the photoproducts might be altered compared with MP.

Surgical Treatment for Giant Multiple Coronary Artery Aneurysms Caused by an IgG4-Related Disease.

Coronary artery aneurysms (CAAs) due to an immunoglobulin G4 (IgG4)-related disease (IgG4-RD) are relatively rare, and there is no consensus on the choice of treatment method. In the present study, we report the results of the surgical treatment for multiple giant CAAs caused by IgG4-RD. A 71-year-old man was diagnosed with severe aortic regurgitation and CAAs. A blood test showed high IgG4 levels, and computed tomography revealed four giant coronary artery aneurysms: two in the right coronary artery (RCA) (proximal RCA and posterior descending artery (PDA)), one in the left anterior descending (LAD), and one in the diagonal branch (Dx). We planned aortic valve replacement, coronary aneurysm resection, and coronary artery bypass grafting (CABG). After finishing aortic valve replacement, the CAAs in proximal RCA, LAD, and Dx were resected. The proximal and distal tracts of the aneurysm were closed with a pericardial bovine patch and ligation. However, since the distal PDA was too calcified to be anastomosed, and the PDA aneurysm was smaller than the others, it was decided to leave the PDA aneurysm. The anastomoses of SVG-RCA and Dx, as well as the left internal thoracic artery to LAD, were performed. Histopathological examination of the aneurysm wall showed a high IgG4-positive cell/IgG-positive cell ratio, and a diagnosis of IgG4-RD was made. In the treatment of CAAs due to IgG4-RD, it is essential to select a procedure that takes into account the size, location, and nature of the aneurysm, and comorbidities. To ensure resection of the aneurysm and blockade of blood flow, closure of the inflow and outflow tracts with a pericardial bovine patch and CABG are effective.

Diagnosis of Type IV Endoleak After Endovascular Aneurysm Repair Using Visualization With Novel Software.

A Type IV endoleak is a very rare complication following endovascular aneurysm repair (EVAR) and differential diagnosis can be difficult. Reported here is a case that showed the development of a Type IV endoleak after an EVAR procedure, for which a novel software was useful to differentiate that from Type I based on visual confirmation. The 89-year-old man was diagnosed with a large abdominal aortic aneurysm, sized 70 mm, as shown by computed tomography (CT). EVAR was performed in a routine fashion using an Endurant II stent graft. Postoperative CT revealed a massive endoleak around the neck that was difficult to differentiate between Types I and IV. The use of the novel software Viewtify (SCIEMENT, Inc., Tokyo, Japan) to visualize the endoleak with surrounding tissues as real-time three-dimensional computer graphics (3DCG) resulted in confirmation that the endoleak was not from the proximal end but rather the stent graft body. CT findings obtained one week later showed that the endoleak had diminished and no additional procedures were needed. Following a diagnosis of endoleak after EVAR, images viewed with Viewtify helped to confirm the appropriate diagnosis. This novel software was found useful to clarify the position and mechanism of a Type IV endoleak.

Cardiac tamponade complicating esophagectomy and retrosternal gastric tube reconstitution in a patient with an abnormal ascending aorta position: a case report.

BACKGROUND: Cardiac tamponade is a rare postoperative complication of esophageal cancer surgery, which leads to rapid hemodynamic changes and can be fatal if not treated properly and promptly. Herein, we report a case of cardiac tamponade after thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution for esophageal cancer that was successfully treated with surgical drainage. CASE PRESENTATION: An 86-year-old man with lower thoracic esophageal cancer underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution. No intra-operative complications were observed. On the first postoperative day, tachycardia and hypotension were observed, and pericardial effusion was identified on computed tomography images. The patient was diagnosed with obstructive shock secondary to cardiac tamponade. As percutaneous puncture drainage was not possible due to the presence of a retrosternal gastric tube, pericardiotomy with a small left anterior thoracotomy was performed, and a large amount of hematogenous fluid was drained, which instantly improved circulation. On the second postoperative day, the patient showed decreased pulse pressure, and computed tomography revealed a residual and enlarged hematoma around the right ventricle. The patient underwent surgical drainage and another pericardiotomy with a small right anterior thoracotomy was performed to drain the hematoma. At this time, multiple injuries to the fatty tissue, epicardium, and myocardium with active bleeding were observed on the anterior surface of the right ventricle near the root of the pulmonary artery. In this patient, the ascending aorta ran further to the right and dorsal sides than usual, causing the anterior wall of the right ventricle near the root of the pulmonary artery to be closer to the back of the sternum. This abnormality may have contributed to injury during the creation of the retrosternal pathway, leading to cardiac tamponade. CONCLUSIONS: Cardiac tamponade after esophagectomy can occur because of manipulation during creation of the retrosternal route, with an anomaly in the aortic position being present in this case. Gentle manipulation and selection of the reconstruction route according to the patient's condition are necessary in cases with such anatomical abnormalities.

Hybrid endovascular treatment for complicated aortic dissection concomitant with true lumen obliteration: a case report.

Background: Thoracic endovascular aortic repair (TEVAR) has been widely introduced. However, unestablished transfemoral approach due to true lumen obliteration disables endovascular option. Case summary: A 74-year-old male with a history of 15-year-ago type B aortic dissection presented with chronic bilateral lower extremity claudication. CT angiography revealed that a large entry tear was located at distal to the left subclavian artery. The thoracic aneurysmal degeneration progressed and eventually required repair. True lumen of infrarenal aorta to bilateral common iliac arteries was totally collapsed by false lumen, and the re-entry tear was open at external iliac artery. Initially, we performed recanalization to the collapsed true lumen. Bidirectional approach was taken from right brachial and bifemoral arteries. The covered endovascular reconstruction of aortic bifurcation (CERAB) technique and double D-shape moulding technique (DDMT) was performed to create covered stent configuration. As secondary treatment, 1-debranching TEVAR with axillary artery bypass was successfully performed by utilizing femoral approach. Discussion: This case demonstrated feasibility of two-stage endovascular therapy for thoracic aneurysmal degeneration concomitant with true lumen obliteration. This combined technique of CERAB and DDMT was absolutely effective to minimize type Ⅲ endoleak in infrarenal segment. Hybrid endovascular treatment offered minimally invasive therapy to the patient.

A Novel Method of Real-Time Assessment for Coronary Artery Anastomosis Skill.

PURPOSE: Coronary anastomosis is the most key factor to accomplish coronary artery bypass grafting, which is one of the largest areas in cardiovascular surgery. Although we have organized on-site simulator training courses of coronary anastomosis using BEAT YOUCAN, it became difficult to continue it because of COVID-19. Therefore, we established a real-time evaluation sheet instead of an Objective Structured Assessment of Technical Skills (OSATS) evaluation sheet. The purposes of this study was to develop the real-time assessment system and to prove the correlation between the score obtained by the OSATS and the score obtained by the real-time evaluation system. SUBJECTS AND METHODS: A total of 22 videos from the qualifying round of real-time coronary anastomosis competition evaluated by both the modified OSATS and the real-time evaluation system were utilized in this study. The global rating score of OSATS was compared with the global rating score of real-time evaluation system. RESULTS: When examined the relationship between the OSATS total score and the real-time total score, there was a significant correlation (R = 0.752, p <0.001). The OSATS general definition score and the real-time total score also showed a strong correlation (R = 0.733, p <0.001). CONCLUSIONS: We developed a real-time assessment sheet to evaluate coronary anastomosis. This assessment sheet had a good correlation with the OSATS evaluation sheet.

An operative case of pseudocoarctation with chronic dissection.

A 47-year-old man with a history of hypertension was found to have a prominent aortic knob on routine chest X-ray and was referred to our hospital. Enhanced computed tomography angiography showed severe flexion at the proximal descending aorta with chronic type B dissection localized to the flexion region. Graft replacement of the distal aortic arch was performed. Surgical management of chronic pseudocoarctation dissection is sparsely reported in the literature because of its rare occurrence. We present an operative case of a patient with chronic dissection of distal aortic arch pseudocoarctation.

The evaluation of photochemical behavior of antihistaminic drug triprolidine in an aqueous media.

Photodegradation is widely known as a changer of both the quality and the quantity of several chemical compounds. In this study, we sought to examine the photochemical behavior of triprolidine (TRP), which is a member of the first-generation antihistamine and utilized for a relief of an allergic conditions, in an aqueous media. There are no reports focused on its potential photoproducts and photodegradation pathways in detail to the best of our knowledge. TRP photodegradation induced by ultraviolet light (UV) irradiation was monitored utilizing high-performance liquid chromatography (HPLC), and structural elucidation of the TRP photoproduct was performed by electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS) and nuclear magnetic resonance (NMR). Finally, the mechanism of TRP photodegradation was speculated based on the identified photoproduct. TRP was photodegraded dependent on the irradiation time of UV in proportion to the generation of one TRP photoproduct (TRP-P). Structural determination by LC-ESI-MS/MS and NMR clarified that TRP-P was the geometrical isomer of TRP, which was formed by the cis-trans conversion of double bond. UV irradiation experiment for TRP-P revealed the conversion from it to TRP. It is clarified that cis-trans conversion between TRP and TRP-P is photo-equilibrium reaction and TRP-P is predominant under the condition as this experiment. Toxicological potencies of TRP and TRP-P might not be observed by ProTox-II in silico toxicity evaluation. This is the first study evaluating the photochemical behavior of TRP.

Photodegradation profiling of nitrendipine: evaluation of active pharmaceutical ingredient, tablets and its altered forms.

Nitrendipine (NTR) is a dihydropyridine drug, which is well-known as a photodegradable pharmaceutical. However, the photochemical reaction of NTR has not been evaluated in detail from now. In this study, we perform the photodegradation profiling of NTR for the elucidation of its photochemical behavior. NTR amounts during ultraviolet light (UV) irradiation were monitored using high performance liquid chromatography (HPLC). NTR was photodegraded almost completely within 24 h along with the generation of some photoproducts. Structural determination of two NTR photoproducts were carried out by means of electrospray ionization liquid chromatography tandem mass spectrometry (LC-ESI-MS/MS). Obtained results from this study clarified one novel NTR photoproduct, a nitroso pyridine analogue, in addition to a pyridine analogue. Furthermore, photodegradation pathway of NTR was speculated based on chemical structures of NTR photoproducts to clarify its photochemical behavior. It was proposed that a singlet oxygen molecule might withdraw two hydrogen radicals resulting in the form of a pyridine analogue, and the following reduction of its nitro group might produce a nitroso pyridine analogue. Finally, we evaluated the photostability of NTR tablets and its altered forms, indicating that the change of the dosage form led to a decrease of the photostability of NTR tablets. The obtained results will be helpful for the additional research to evaluate the effect of NTR photodegradation on its own biological activities.

Successful "PETTICOAT" procedure assisted by aortic angioscopy for complicated type B aortic dissection: Case report.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) is a useful treatment for acute type B aortic dissection (TBAD). A PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) procedure can be an alternative surgical option for a patent false lumen. Non-obstructive aortic angioscopy is an attractive modality that can visualize the aortic intima for things such as entry or re-entry tears that are difficult to detect with computed tomography (CT). Herein, we describe a successful PETTICOAT procedure assisted by aortic angioscopy for subacute TBAD complicated by lower limb ischemia. PRESENTATION OF CASE: A 63-year-old man who had been treated with conservative therapy for subacute TBAD had intermittent claudication. Enhanced CT revealed a primary entry tear at the distal arch, and the true lumen at the thoracoabdominal level was narrowed by the patent false lumen. Therefore, the PETTICOAT procedure was performed. The postoperative course was uneventful, with normalized lower limb pressure. DISCUSSION: Although PETTICOAT procedure is effective for treating complicated TBAD, there is no consensus on where and how far the proximal stent graft or distal bare stent should be implanted. Non-obstructive aortic angioscopy during PETTICOAT is useful to detect and cover the entry and re-entry tears. The PETTICOAT procedure assisted by aortic angioscopy could contribute to determining the appropriate coverage range of the stent graft. CONCLUSION: Aortic angioscopy could contribute to the surgical success of PETTICOAT procedure for complicated subacute TBAD.

Extracellular and intracellular productions of lysophosphatidic acids and cyclic phosphatidic acids by lysophospholipase D from exogenously added lysophosphatidylcholines to cultured NRK52E cells.

Lysophosphatidic acid (LPA) is a bioactive lysophospholipid that is a notable biomarker of kidney injury. However, it is not clear how LPA is produced in renal cells. In this study, we explored LPA generation and its enzymatic pathway in a rat kidney-derived cell, NRK52E cells. Culturing of NRK52E cells with acyl lysophosphatidylcholine (acyl LPC), or lyso-platelet activating factor (lysoPAF, alkyl LPC) was resulted in increased extracellular level of choline, co-product with LPA by lysophospholipase D (lysoPLD). Their activities were enhanced by addition of calcium ions to the cell culture medium, but failed to be inhibited by S32826, an autotaxin (ATX)-specific inhibitor. Liquid chromatography-tandem mass spectrometric analysis revealed the small, but significant extracellular production of acyl LPA/cyclic phosphatidic acid (cPA) and alkyl LPA/cPA. The mRNA expression of glycerophosphodiesterase (GDE) 7 with lysoPLD activity was elevated in confluent NRK52E cells cultured over 3 days. GDE7 plasmid-transfection of NRK52E cells augmented both extracellular and intracellular productions of LPAs (acyl and alkyl) as well as extracellular productions of cPAs (acyl and alkyl) from exogenous LPCs (acyl and alkyl). These results suggest that intact NRK52E cells are able to produce choline and LPA/cPA from exogenous LPCs through the enzymatic action of GDE7 that is located on the plasma membranes and intracellular membranes.

Evaluation of photostability of azelnidipine tablets and structure determination of its photoproducts.

Photo-exposure has a crucial effect on the natures of photosensitive pharmaceuticals in addition to their contents in medicines through the photodegradation. Generated photoproducts might be more bioactive and contribute to the expression of adverse side effects. This study aimed to clarify the photochemical behavior of medicines of azelnidipine, which is a member of dihydropyridine antihypertensive drugs, by the evaluation of its photostability and the determination of chemical structures of generated photoproducts. Calblock® tablets and its altered forms (powders and suspensions) were UV-irradiated by a black light. Residual amounts of active pharmaceutical ingredients (APIs) were monitored by high-performance liquid chromatography. The chemical structures of two photoproducts were determined by electrospray ionization tandem mass spectrometry. API of Calblock® tablets was photodegraded with the generation of several photoproducts. Its photodegradability was more significant when Calblock® tablets were crushed or suspended. Structural determination revealed that two photoproducts were benzophenone and a pyridine derivative. It was speculated that these photoproducts were generated by the elimination of diphenyl methylene radical and additional chemical reaction including oxidation and hydrolysis. Azelnidipine was photosensitive and its photodegradation in Calblock® tablets was promoted by the change of the dosage form. This difference might be derived from the light emission efficiency. This study suggests that API contents of Calblock® tablets might decrease when tablets or its altered forms are exposed to sunlight irradiation with the generation of benzophenone, which is a toxicological potent.

Phospholipid analysis of two influenza A virus-infected cell lines differing in their viral replication kinetics.

Fluctuations in phospholipid composition in infected cells during influenza A virus replication were analyzed using two different susceptible host cell lines: H292 cells, exhibiting a rapid cytopathic effect, and A549 cells, exhibiting a retarded cytopathic effect. Microarray analysis demonstrated that A549 cells recognized influenza A virus invasion, expression of pathogen recognition genes was affected, and antiviral genes were activated. On the other hand, H292 cells did not display such an antiviral state, and in these cells, rapid virus amplification and a rapid cytopathic effect were observed. Levels of ceramide, diacylglycerol, and lysolipids were higher in virus-infected cells than in the corresponding mock-infected cells at the later stages of infection. The accumulation of these lipids in IAV-infected cells occurred together with viral replication. The relationship between the characteristic features of ceramide, diacylglycerol, and lysolipid in the plasma membrane, where enveloped viruses are released, and their role in viral envelope formation are discussed. Our results indicate that viral replication disturbs cellular lipid metabolism, with consequences for viral replication kinetics.

Prolonged Sedentary Bouts Are Critically Involved in All-Cause Mortality in Patients on Chronic Hemodialysis: A Prospective Cohort Study.

We investigated the link between prolonged sedentary bouts and all-cause mortality in patients on chronic hemodialysis, using a prospective cohort. A total of 104 outpatients on chronic hemodialysis from 2013 to 2019, aged 71.4±11.4 years, were enrolled. Prolonged sedentary bouts (≥ 30 min and ≥60 min) (min and bouts) and relative prolonged sedentary bouts (≥ 30 min and ≥ 60 min) (%) on the patients' non-hemodialysis days were measured by a tri-accelerometer, and we also analyzed the patients' clinical parameters. The relationship between prolonged sedentary bouts and all-cause mortality was evaluated by a survival analysis and the Cox proportional hazard model. Thirty-five patients died during the follow-up period. A Kaplan-Meier analysis detected significant differences in the survival rate between two groups stratified by the median for all prolonged sedentary-bout parameters. After the adjustment for confounding factors, all of the prolonged sedentary-bout parameters were determinant factors for all-cause mortality. These results indicate that prolonged sedentary bouts on non-hemodialysis days were closely related to all-cause mortality in the patients on hemodialysis.

Structure Determination of Felodipine Photoproducts in UV-Irradiated Medicines Using ESI-LC/MS/MS.

Dihydropyridine drugs are well known as photodegradable pharmaceuticals. Herein, we evaluate the photostability of felodipine (FL) medicine (Splendil® (SPL) tablets) and its altered forms (powders and suspensions). FL is a type of dihydropyridine drug, but its photochemical behavior is unknown. FL contents after ultraviolet light (UV) irradiation for 24 h were monitored using high-performance liquid chromatography (HPLC). Values of the residual amounts of FL in UV-irradiated SPL powders and suspensions were 32.76 ± 4.88% and 0.79 ± 0.74%, respectively, with the generation of two photoproducts (FL photoproduct 1 and 2). To identify the chemical structures of these photoproducts, electrospray ionization liquid chromatography mass spectrometry (ESI-LC/MS/MS) analysis was performed. Based on their mass-to-charge ratio values and fragment patterns, it was proposed that FL photoproduct 1 was a pyridine derivative and FL photoproduct 2 was an FL dimer. Interestingly, generation rates of FL photoproduct 1 and 2 were dependent on the presence of the aqueous media. The photodimerization of FL was induced in UV-irradiated SPL suspensions. This is the first report evaluating the photostability of SPL tablets and its altered forms and estimating FL photoproducts induced by UV irradiation in the formulation of SPL.

Successful concomitant minimally invasive surgery for aortic valve stenosis and right lung cancer via right mini-thoracotomy : A case report.

BACKGROUND: The case of aortic valve stenosis complicated with lung cancer have compelled cardiovascular surgeons to make challenging. We report the first successful short-term outcomes of one-stage minimally invasive aortic valve replacement and video-assisted thoracoscopic surgery lobectomy through right mini-thoracotomy in a patient with synchronous bicuspid severe aortic valve stenosis which was unsuitable for transcatheter aortic valve implantation and right lung cancer. CASE PRESENTATION: A 76-year-old man with severe aortic valve stenosis was diagnosed with lung cancer of the right upper lobe with stage IA2. Considering the potential risk of tumor metastasis, a one-stage surgical therapy for right lung cancer and type 0 bicuspid aortic valve stenosis was required; however, transcatheter aortic valve implantation was unsuitable due to a bicuspid aortic valve with severe calcification. Therefore, concomitant minimally invasive aortic valve replacement and lobectomy via right mini-thoracotomy were performed. The postoperative course was uneventful. CONCLUSION: Concomitant aortic valve replacement and right lobectomy via right mini-thoracotomy may reduce surgical invasiveness, leading to early recovery. This surgical strategy is a useful option, particularly for patients with aortic valve stenosis complicated with right lung cancer.

Relation between Prolonged Sedentary Bouts and Health-Related Quality of Life in Patients on Chronic Hemodialysis.

This study aimed to investigate the link between prolonged sedentary bouts and health-related quality of life (QOL) in patients on chronic hemodialysis (CHD). A total of 84 outpatients on CHD, aged 71.6±11.8 years, were enrolled in this cross-sectional study. Parameters for prolonged sedentary bouts [i.e., ≧ 30 min (% and bout) and ≧ 60 min (% and bout)] were measured using a triaxial accelerometer. Health-related QOL (HRQOL) was evaluated by the Euro-QOL (EQ-5D). Clinical parameters were obtained from medical records. Relatively prolonged sedentary bouts (%) were 44.0±18.2 (≧ 30 min) and 29.8±16.5 (≧ 60 min) for total days. Prolonged sedentary bouts (bouts) were 6.2±2.7 (≧ 30 min) and 2.7±1.6 (≧ 60 min) for total days. EQ-5D scores were 0.728±0.220. All prolonged sedentary bout parameters were negatively correlated with EQ-5D scores, except for prolonged sedentary bouts (≧ 60 min) (min) and relatively prolonged sedentary bouts (%) on hemodialysis days. Multiple regression analysis showed that prolonged sedentary bout parameters were an important factor in EQ-5D scores even after adjusting for confounding factors for total and non-hemodialysis days. Our results suggested that prolonged sedentary bouts were closely associated with HRQOL in patients on CHD, especially on non-hemodialysis days.

A high prevalence of myeloid malignancies in progeria with Werner syndrome is associated with p53 insufficiency.

Werner syndrome (WS) is a progeroid syndrome caused by mutations in the WRN gene, which encodes the RecQ type DNA helicase for the unwinding of unusual DNA structures and is implicated in DNA replication, DNA repair, and telomere maintenance. patients with WS are prone to develop malignant neoplasms, including hematological malignancies. However, the pathogenesis of WS-associated hematological malignancies remains uncharacterized. Here we investigated the somatic gene mutations in WS-associated myelodysplastic syndrome/acute myeloid leukemia (MDS/AML). Whole-exome sequencing (WES) of 4 patients with WS with MDS/AML revealed that all patients had somatic mutations in TP53 but no other recurrent mutations in MDS/AML. TP53 mutations were identified at low allele frequencies at more than one year before the MDS/AML stage. All 4 patients had complex chromosomal abnormalities including those that involved TP53. Targeted sequencing of nine patients with WS without apparent blood abnormalities did not detect recurrent mutations in MDS/AML except for a PPM1D mutation. These results suggest that patients with WS are apt to acquire TP53 mutations and/or chromosomal abnormalities involving TP53, rather than other MDS/AML-related mutations. TP53 mutations are frequently associated with prior exposure to chemotherapy; however, all four patients with WS with TP53 mutations/deletions had not received any prior chemotherapy, suggesting a pathogenic link between WRN mutations and p53 insufficiency. These results indicate that WS hematopoietic stem cells with WRN insufficiency acquire competitive fitness by inactivating p53, which may cause complex chromosomal abnormalities and the subsequent development of myeloid malignancies. These findings promote our understanding of the pathogenesis of myeloid malignancies associated with progeria.

Successful redo aortic valve replacement using Perceval for multiple recurrent prosthetic valve dysfunction.

A 50-year-old man who required aortic valve replacement (AVR) 3 times for severe paravalvular leakage (PVL) was diagnosed with a recurrence of severe PVL. Since the PVL recurred each time because of prosthetic valve detachment from the annulus, a fourth AVR was performed using a self-expanding sutureless valve. Postoperative echocardiography showed no significant PVL. The patient was discharged without any complications and returned to normal work soon after. In cases such as our patient, sutureless AVR could be a powerful alternative to conventional AVR.

Efficacy of simulation training for beating heart coronary anastomosis using BEAT + YOUCAN simulator.

BACKGROUND: We sought to evaluate our distributed practice program developed for training for beating heart anastomosis by employing a novel beating heart simulator. METHODS: Eleven trainees watched and reviewed instructional video recordings of coronary anastomosis methods with a BEAT + YOUCAN training device, then performed coronary anastomosis procedures under a beating condition. Next, they participated in a four-hour training program developed by faculty surgeons. Ten different anastomosis components were assessed on a five-point rating scale (5, good; 3, average; 1, poor). After finishing the training program, each trainee again performed a coronary anastomosis procedure. Component scores were then compared before and after the training program. RESULTS: The mean time to completion of the procedure improved from 1033 ± 424 to 795 ± 201 s (p < 0.05). Assessment scores improved from 1.88 ± 0.41 to 2.57 ± 0.30 (p < 0.05). Improvements in some technical components related to handling of instruments were noted (p < 0.05), whereas no significant improvement was seen with arteriotomy, graft orientation, suture management, or knot tying after finishing the training program. CONCLUSION: Trainees who participated in our four-hour focused training program for coronary anastomosis with a novel beating heart simulator showed improved ability under the beating condition in regard to technical skills related to handling instruments.