Heart valve surgery in hemodialysis-dependent patients: nutrition status impact on surgical outcome.

Valve surgery in hemodialysis-dependent patients is associated with postoperative complications and a high mortality rate, and such patients frequently suffer cachexia. This study aimed to determine pre- and intraoperative risk factors associated with in-hospital mortality and long-term survival in hemodialysis-dependent patients undergoing heart valve surgery from the viewpoint of nutrition status. Eighty-seven hemodialysis-dependent patients who underwent valve surgery between January 1998 and October 2015 were retrospectively reviewed. Thirty-seven potential perioperative risk factors were evaluated. The in-hospital mortality rate was 12.6 % (11 patients). Univariate analysis identified New York Heart Association Functional Classification III or IV, emaciation (body mass index <17.6 kg/m(2)), total cholesterol <120 mg/dl, serum albumin <3.0 mg/dl, emergent/urgent surgery, and intraoperative blood transfusion >3000 ml as predictors of in-hospital death. Multivariate logistic regression analysis confirmed low serum albumin <3.0 mg/dl (hazard ratio 7.22; p = 0.032) and emergent/urgent operation (hazard ratio 43.57; p = 0.035) as independent predictors of in-hospital death. The 1- and 3-year actuarial survival rates were 64.9 ± 5.4 and 51.8 ± 5.8 %, respectively. Long-term survival estimated by log-rank test was negatively impacted by anemia (hemoglobin <10 mg/dl), low serum albumin, emergent/urgent operation, and infective endocarditis. Multivariate analysis using Cox proportional hazards modeling indicated low serum albumin (hazard ratio 2.12; p = 0.047) and emergent/urgent operation (hazard ratio 8.97; p = 0.0002) as independent predictors of remote death. Hypoalbuminemia and emergent/urgent operation are strong predictors of in-hospital and remote death. Malnutrition before surgery should be considered for operative risk estimation, and adequate preoperative nutrition management may improve surgical outcomes for hemodialysis-dependent patients.

[Clinical Results of Diffractive Multifocal Intraocular Lens Implantation after Laser In Situ Keratomileusis].

PURPOSE: To evaluate the visual performance in eyes with diffractive intraocular lenses (IOLs) after laser in situ keratomileusis (LASIK). METHODS: This single-center retrospective study evaluated eyes that had diffractive multifocal IOL implantation after previous LASIK or not treated with LASIK (controls). The outcomes' measures were the visual acuities (VAs) at distance and near, spherical equivalent (SE) and contrast sensitivity at one month postoperatively. RESULTS: The study evaluated 40 eyes of 33 patients. The mean uncorrected logMAR VAs were -0.05 ± 0.13/0.00 ± 0.14 (LASIK group/control group) at distance and 0.10 ± 0.13/0.16 ± 0.18 at near. There was no statistically significant difference between the 2 groups at the VAs. The SE of the LASIK group was -0.06 ± 0.39 D, significantly lower than the control group (0.22 ± 0.45 D) (p < 0.05). The contrast sensitivity of the LASIK group at high spatial frequency was lower than the control group (p < 0.05). CONCLUSION: After LASIK, the diffractive multifocal IOL provided good uncorrected distance and near VAs. However, decrease in contrast sensitivity should be considered.

[Aortic arch and valve replacement in a hemodialysis patient with a porcelain aorta;report of a case].

We report a case of thoracic aortic aneurysm and aortic valve stenosis with chronic renal failure requiring hemodialysis. A 75-year-old man complained of back pain and hoarseness. He had been on dialysis for 15 years. A computed tomography scan of the chest showed marked calcification in the thoracic aortic arch, which is known as a porcelain aorta, and a distal arch aneurysm. Echocardiographic examination showed moderate aortic valve stenosis with calcification. An operation was scheduled, and both the aortic valve and the aortic arch aneurysm were successfully replaced with a mechanical valve and a prosthetic graft. Cardiovascular surgery for patients complicated by a porcelain aorta requires extra cares for the establishment of cardiopulmonary bypass and anastomoses of the aorta.

[Mitral valve repair for active infectious endocarditis].

Between December 2005 and November 2011, 11 patients with mitral valve regurgitation (MVR) resulting from native valve endocarditis underwent mitral valve plasty (MVP). These patients were aged 44.4 ± 11.3 years. The mean follow-up period of the patients was 3.1 ± 0.63 years. Five patients were men. Emergency or urgent surgery was required in 5 patients. Three patients were categorized as New York Heart Association( NYHA) functional class IV. Infection of the mitral valve, occurred in the anterior leaflet in 3 patients, the posterior leaflet in 5 patients, and the anterior-posterior leaflet in 3 patients. Nine patients had a resection suture technique. One patient had chordae replacement with expanded polytetrafluoroethylene (ePTFE), and 1 patient had replacement using the pericardium. All patients received ring annuloplasty with a partial flexible ring. After surgery, all patients were categorized as NYHA functional class I. There were no valve associated complications, no hospital deaths, no late deaths, and no reoperations. We conclude that MVP is an effective treatment for active infective endocarditis( AIE) with mitral regurgitation.

Subjective and objective refractions in eyes with extended-depth-of-focus intraocular lenses using echelette optics: clinical and experimental study.

PURPOSE: To evaluate differences in subjective and objective refractions in eyes with extended-depth-of-focus intraocular lenses (EDOF IOLs) using echelette optics, and the effect of the light wavelength used during examinations. METHODS: In the prospective study, subjective and objective refractions of 128 eyes of 64 patients were examined 3 months after implantation of the EDOF IOLs (ZXR00V, Johnson & Johnson Surgival Vision). Objective refractions were measured using an autorefractor with a near-infrared (NIR) light source. Clinical differences in the spherical, cylindrical and spherical equivalent (SE) refractions between the subjective and objective refractions were evaluated. Then, lens powers of monofocal, EDOF and diffractive bifocal IOLs in the use of a 850-nm light source were measured experimentally for using a lensmeter, and the differences from the monofocal IOLs were calculated. RESULTS: The mean objective refractions were more myopic (p < 0.001) than the subjective refractions; the differences in the spherical, cylindrical and SE refractions were -0.71, -0.26 and -0.84 dioptre, respectively. Experimental investigation resulted that there was the mean difference of 0.83 D with the EDOF from monofocal IOLs at 850 nm, while the difference was -0.20 D with bifocal IOLs. CONCLUSIONS: The diffractive EDOF IOLs using echelette gratings inherently induced constant differences in the subjective and objective refractions, which arose from the chromatic difference in IOL powers for the visible and NIR lights.

Efficacy of Femtosecond Laser-Assisted Capsulotomy: Experimental Evaluation Using the Zonular Dehiscence Model.

Purpose: The purpose of this study was to evaluate experimentally the efficacy of femtosecond laser (FL)-assisted capsulotomy using an eye model with different degrees of zonular dehiscence (ZD). Methods: An eye model with ZD was created by removing the total iris and including the planned range of the ZD in porcine and human cadaver eyes. FL-assisted capsulotomies (laser group) and manual capsulotomies (manual group) were created for the eye model with 0, 45, 135, 180, and 270 degrees of ZD. The continuity, mean diameter, ellipticity, and decentration of the capsulotomy were evaluated using the captured images. The same evaluation of FL-assisted capsulotomies was done for five human cadaver eyes with 180 degrees of ZD. Results: In the laser group, no differences were seen in the mean diameter, ellipticity, and decentration, although the manual group resulted in significantly larger, ovalized, and decentered capsulotomies with different degrees of ZD (P < 0.001, P < 0.001, and P = 0.0317, respectively). Continuous capsulotomies or capsulotomies with microadhesions were obtained up to 180 degrees of ZD, and incomplete treatment areas were seen in eyes with 270 degrees of ZD. Capsulotomy of the human cadaver eyes with 180 degrees of ZD showed similar results to those of porcine eyes. Conclusions: In this experimental study, FL-assisted capsulotomy showed favorable results in eyes with between 0 and 180 degrees of ZD compared to conventional manual capsulotomy. Translational Relevance: Our experimental model can simulate the capsulotomy in cases with ZD, the results are useful when determining the indication for FL-assisted capsulotomies.

Pupil sizes in different Japanese age groups and the implications for intraocular lens choice.

PURPOSE: To observe pupil sizes with near and distance vision under different lighting conditions in different Japanese age groups. SETTING: Department of Ophthalmology, Tokyo Dental College Suidobashi Hospital, Tokyo, Japan. METHODS: Using an open view-type infrared video pupillometer, the horizontal and vertical pupil sizes were measured prospectively with subjects gazing at 30 cm or 3 m targets under photopic (illumination 500 lux) and mesopic (illumination 5 lux) conditions. The results were analyzed by age, and the benefits with various multifocal IOLs were evaluated. RESULTS: The study comprised 140 eyes (70 subjects; 14 to 94 years). The mean +/- standard deviations of photopic vertical pupil sizes when gazing far/near decreased from 3.77 +/- 0.23/3.50 +/- 0.33 mm (<20 years) to 2.20 +/- 0.30/1.95 +/- 0.20 mm (over 80 years), with pupil sizes stabilizing after 60 years. The mesopic vertical pupil sizes when gazing far/near decreased from 6.35 +/- 0.11/6.27 +/- 0.14 mm (<20 years) to 3.42 +/- 0.30/3.21 +/- 0.28 mm (over 80 years). The pupil sizes decreased with age until 60 years and stabilized (1-way analysis of variance, P<.05). Fewer than 50% of subjects over 60 years of age had pupil sizes conducive to the near zone of refractive multifocal intraocular lenses. CONCLUSION: Photopic and scotopic pupil sizes decreased with age up to 60 years. The pupil was smaller when gazing at a near target than previously reported.

Visual Performance After Contralateral Implantation of Multifocal Intraocular Lenses With +3.0 and +4.0 Diopter Additions.

PURPOSE: To evaluate visual performance after contralateral implantation of AcrySof ReSTOR aspheric intraocular lenses (IOLs) with +3.0 and +4.0 diopter near additions. DESIGN: This was a retrospective case study conducted at Tokyo Dental College Suidobashi Hospital in Tokyo, Japan. METHODS: Eleven patients who were implanted with the SN6AD1 IOL and the SN6AD3 IOL contralaterally were included in this study. The distance, intermediate (1 m, 50 cm), and near (40 and 30 cm) uncorrected and corrected binocular visual acuity (VA), contrast sensitivity, depth of focus, and patient satisfaction were assessed more than 1 month postoperatively. RESULTS: Postoperatively, the mean uncorrected (corrected) binocular logarithm of the minimum angle of resolution VA levels were as follows: distance, -0.120 (-0.163); intermediate, 1 m, 0.226 (0.012) and 50 cm, 0.037 (0.006); and near, 40 cm, 0.067 (-0.040) and 30 cm, 0.091 (-0.053). The depth of focus had a smooth curve with double peaks. The mean contrast sensitivity was normal at all spatial frequencies. All patients were spectacle independent and expressed high satisfaction. CONCLUSIONS: Contralateral implantation of multifocal IOLs with +3.0 and +4.0 D additions takes advantage of the good uncorrected near VA provided by both IOLs and may be an option for patients who require a broader range of good uncorrected near VA.

A repair of funnel chest without sternal dissection in aortic root replacement.

A 46-year-old man with Marfan syndrome was admitted for repair of annuloaortic etasia and funnel chest. Before median sternotomy, seven transverse skin incisions were made for resection of deformed ribs. The convex portions at the costochondral junctions of the right 4 approximately 7th and left 5 approximately 7th ribs were removed. Thereafter, the conventional median sternotomy was safely performed. Aortic root was replaced. After weaning from the cardiopulmonary bypass, the redundant distal end of the sternum was resected, fractured sites of the concave sternum were straightened and secured with wire fixation, and the split sternum was sutured with wires in an ordinary fashion.

Management of anomalous right coronary arteries encountered during aortic valve surgery.

We experienced three cases with anomalous right coronary arteries during aortic valve surgery. By rotating a Freestyle bioprosthesis by a subcoronary technique, the anomalous artery was secured in one patient. The anomalous artery was injured during the routine aortotomy incision in another patient; a saphenous vein graft was interposed between the ascending aorta and the separated artery. In the third patient, a subannular prosthetic valve was chosen to avoid obstructing the anomalous orifice.

Twenty-two year experience with the omniscience prosthetic heart valve.

This study was designed to evaluate the long-term clinical results of the Omniscience tilting disc valve. Omniscience valves were implanted in 51 patients (mean age, 50 +/- 10 years); 18 had aortic valve, 24 had mitral valve, and 9 had both aortic and mitral valve replacements. Oral warfarin potassium and dipyridamole were prescribed as our anticoagulant therapy. Preoperatively, 42 patients were in New York Heart Association class III or IV, and 23 of 25 surviving patients were in class I or II after operation. There were 2 (3.9%) early deaths and 23 late deaths (3.5 +/- 0.7% per patient-year). Cardiac related mortality including congestive heart failure, sudden death, and thromboembolism, and hemorrhagic complications were seen in 16 patients. Overall survival at 10, 15, and 20 years was 77 +/- 6%, 62 +/- 7%, and 46 +/- 7%, respectively. Thromboembolic complications were seen in 5 patients, for a rate of 0.8 +/- 0.3% per patient-year; similarly, hemorrhagic complications were also seen in 5 patients. Nonstructural prosthetic valve dysfunction was seen in 4 patients, for a rate of 0.6 +/- 0.3% per patient-year, and sudden death was seen in 2, a rate of 0.3 +/- 0.2% per patient-year. The Omniscience prosthesis demonstrated excellent postoperative clinical status with low rates of valve related complications.

When and how does nonstructural mechanical prosthetic heart valve dysfunction occur?

OBJECTIVE: We discuss the clinical aspects related to mechanical valve dysfunction based upon 20 years' experience of our cases. METHODS: Between January 1982 and December 2001, 21 patients underwent surgical interventions because of mechanical valve dysfunction. Thirteen men and 8 women (mean age 47 +/- 20, range 3-75 years-old), were included. RESULTS: Mitral valve dysfunction was observed in 12 patients. Prosthetic valve stenosis occurred in 6 patients between 2 and 224 months, and paravalvular leaks in 4 between 1 and 71 months after surgery. The other 2 patients suffered from hemolytic anemia with mild paravalvular leaks between 102 and 104 months after surgery. Aortic valve dysfunction was observed in 8 patients including 3 stenotic lesions between 48 and 97 months and 5 paravalvular leaks between 3 and 150 months after surgery. Tricuspid regurgitation was seen in 1 patient with a huge right atrium at 42 months after surgery. Early death was seen in 1 patient. Late death occurred in 1 patient, 17 years after operation. Survival, including early death, was 95.2%, at 10 and 15 years. One valve-related complication of bioprosthetic valve endocarditis at the mitral and tricuspid positions occurred 12 years after a reoperation. The freedom from complications was 95.2% at 10 years, and 76.2% at 15 years. CONCLUSIONS: Paravalvular leaks without overt endocarditis had latency periods of up to 12 years, and pannus formation was observed 20 years after surgery. Early and late clinical results after surgery for mechanical valve dysfunction were excellent.

Infection of pacemaker lead by penicillin-resistant Streptococcus Pneumoniae.

Penicillin-resistant Streptococcus pneumoniae (PRSP) infections have steadily increased worldwide; however, there are only a few reports of permanent pacemaker-related infections caused by PRSP. Here, we describe a patient who developed 7 episodes of endocarditis and sepsis from PRSP infection of the pacemaker lead in the right atrium. By periodic administration of vancomycin and extraction of both leads, we resolved the infection.

Two-year follow-up after implantation of diffractive aspheric silicone multifocal intraocular lenses.

PURPOSE: To evaluate the stability of visual performance after implantation of a diffractive aspheric silicone multifocal intraocular lens (MIOL). METHODS: Thirty eyes of 15 patients received the Tecnis MIOL ZM900 (Abbot Medical Optics) after cataract extraction at Tokyo Dental College Suidobashi Hospital. The uncorrected and best-corrected distance visual acuities (UCDVA, BCDVA); uncorrected, distance-corrected and best-corrected near VAs (UCNVA, DCNVA and BCNVA); spherical equivalent refraction, spectacle independence, contrast sensitivity and posterior capsule opacification (PCO) were measured at 1 week; 1, 3 and 6 months; and 1 and 2 years postoperatively. RESULTS: Two years postoperatively, the UCDVA was 0.01 logMAR, BCDVA -0.09 logMAR, UCNVA 0.19 logMAR, DCNVA 0.1 logMAR and BCNVA 0.04 logMAR. There was no significant change from 1 week through 2 years. The percent of spherical equivalent refraction error within ± 0.5 diopter was 63.4% at 2 years. No patient required spectacles for reading; two patients have used spectacles for intermediate vision when necessary. One eye underwent Nd:YAG laser posterior capsulotomy because of PCO. CONCLUSION: The visual performance after implantation of the Tecnis MIOL was stable for 2 years. A low rate of PCO contributed to the long-term visual performance.

Asymptomatic papillary fibroelastoma of the mitral valve.

We report an asymptomatic case of a papillary fibroelastoma adherent to the mitral anterior leaflet. Transthoracic echocardiography of an 85-year-old man with chronic atrial fibrillation and no thromboembolic episodes, revealed a cardiac tumor on the mitral valve. Transesophageal echocardiography demonstrated typical findings for a papillary fibroelastoma. The tumor was successfully removed using a shave excision technique. Currently, these tumors are found incidentally in asymptomatic patients by advanced diagnostic modalities.

Clinical experience with the Bicarbon heart valve prosthesis.

BACKGROUND: We have previously reported mid-term results of a study, which ended in January 2000, on the Bicarbon valve. The study concluded that the valve showed excellent clinical results, associated with a low incidence of valve-related complications. In the present study, the same patients were prospectively followed for an additional 5 years. METHODS: Forty-four patients had aortic valve replacement (AVR), 48 had mitral valve replacement (MVR), and 13 had both aortic and mitral valve replacement (DVR). The mean age of the 105 patients was 61.2 +/- 11.3 years. The mean follow-up was 6.1 +/- 1.9 years with a cumulative follow-up of 616 patient-years. RESULTS: There were 5 early deaths (4.7%: 4 in the AVR group and 1 in the MVR group) and 21 late deaths (3.4%/patient-year: 5 valve related deaths and 16 valve unrelated deaths). Survival at 8 years was 75.2 +/- 7.0% in the AVR group, 76.6 +/- 6.2% in the MVR group, and 55.4 +/- 16.1% in the DVR group. The linearized incidence of thrombo-embolic complications, hemorrhagic complications, and paravalvular leaks in all patients was 0.65 +/- 1.48%, 0.81 +/- 1.69%, and 0.16 +/- 0.54%/patient-year respectively. No other complications were observed. CONCLUSION: The Bicarbon prosthetic heart valve has shown excellent long-term clinical results, associated with a low incidence of valve-related complications.

Single-center experience with the bicarbon bileaflet prosthetic heart valve in Japan.

We analyzed midterm results using the Bicarbon valve in a single center. Forty-four patients had aortic valve replacement (AVR), 48 had mitral valve replacement (MVR), and 13 had both aortic and mitral valve replacement (DVR). The mean age of the 105 patients was 61.2 +/- 11.3 years. The mean follow-up was 1.8 +/- 1.1 years with a cumulative follow-up of 188 patient-years. There were 5 early deaths (4.7%: 4 in the AVR group and 1 in the MVR group) and 5 late deaths (2.7% per patient-year: 3 malignancy, 1 cerebral hemorrhage, 1 myocardial infarction). Survival at 3 years was 91 +/- 4% in the AVR group, 92 +/- 5% in the MVR group, and 66 +/- 23% in the DVR group. The linearized incidence of thromboembolic complications, hemorrhagic complications, and paravalvular leaks in all patients was 1.06 +/- 2.34%, 1.60 +/- 2.53%, and 0.53 +/- 2.22% per patient-year, respectively. No other complications were observed. In conclusion, the Bicarbon prosthetic heart valve has shown excellent clinical results associated with a low incidence of valve-related complications.