Effects of oral nicorandil therapy on sympathetic nerve activity and cardiac events in patients with chronic heart failure: subanalysis of our previous report using propensity score matching.

PURPOSE: Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, improves cardiac sympathetic nerve activity (CSNA) in patients with ischaemic heart disease. However, the long-term effects on both CSNA, as evaluated by (123)I-metaiodobenzylguanidine (MIBG) scintigraphy, and prognosis have not been determined in patients with chronic heart failure (CHF). METHODS: This study was a subanalysis of our previous results that serial (123)I-MIBG scintigraphic studies are the most useful prognostic indicator in CHF patients. The study group comprised 208 patients with CHF (left ventricular ejection fraction <45 %) but no cardiac events for at least 5 months identified on the basis of a history of decompensated acute heart failure requiring hospitalization. These patients underwent (123)I-MIBG scintigraphy and echocardiography just before leaving the hospital and again 6 months later. We selected 170 patients and used propensity propensity score matching to compare patients who received oral nicorandil (85 patients) and those who did not (85 patients). The patients were followed up for a median of 5.03 years, with the primary and secondary study end-points defined as the occurrence of a fatal cardiac event and a major adverse cardiac event (MACE), respectively. RESULTS: After treatment, the extent of changes in (123)I-MIBG scintigraphic and echocardiographic parameters in the nicorandil group were more favourable than in those not receiving nicorandil. Of the 170 patients, a fatal cardiac event occurred in 42, and a MACE in 68 during the study. Multivariate Cox regression analyses revealed that no nicorandil treatment was a significant predictor of both cardiac death and MACE in our patients with CHF. On Kaplan-Meier analysis, the rates of freedom from cardiac death or from MACE in the nicorandil group were significantly higher than in those not receiving nicorandil (all p<0.05). CONCLUSION: Long-term nicorandil treatment improves CSNA and left ventricular parameters in patients with CHF. Furthermore, this agent is potentially effective for reducing the incidence of cardiac events in patients with CHF.

Evaluation of cardiac sympathetic nerve activity and aldosterone suppression in patients with acute decompensated heart failure on treatment containing intravenous atrial natriuretic peptide.

PURPOSE: Aldosterone prevents the uptake of norepinephrine in the myocardium. Atrial natriuretic peptide (ANP), a circulating hormone of cardiac origin, inhibits aldosterone synthase gene expression in cultured cardiocytes. We evaluated the effects of intravenous ANP on cardiac sympathetic nerve activity (CSNA) and aldosterone suppression in patients with acute decompensated heart failure (ADHF). METHODS: We studied 182 patients with moderate nonischemic ADHF requiring hospitalization and treated with standard therapy containing intravenous ANP and 10 age-matched normal control subjects. ANP was continuously infused for >96 h. In all subjects, delayed total defect score (TDS), heart to mediastinum ratio, and washout rate were determined by 123I-metaiodobenzylguanidine (MIBG) scintigraphy. Left ventricular (LV) end-diastolic volume, end-systolic volume, and ejection fraction were determined by echocardiography. All patients with acute heart failure (AHF) were examined once within 3 days and then 4 weeks after admission, while the control subjects were examined only once (when their hemodynamics were normal). Moreover, for 62 AHF patients, plasma aldosterone concentrations were measured at admission and 1 h before stopping ANP infusion. RESULTS: 123I-MIBG scintigraphic and echocardiographic parameters in normal subjects were more favorable than those in patients with AHF (all p < 0.001). After treatment, all these parameters improved significantly in AHF patients (all p < 0.001). We also found significant correlation between percent changes of TDS and aldosterone concentrations (r = 0.539, p < 0.001) in 62 AHF patients. CONCLUSION: The CSNA and LV performance were all improved in AHF patients. Furthermore, norepinephrine uptake of myocardium may be ameliorated by suppressing aldosterone production after standard treatment containing intravenous ANP.

Three-year survival after surgery for primary malignant pericardial mesothelioma: report of a case.

A 59-year-old female underwent surgery for a primary malignant pericardial mesothelioma. She presented with progressive dyspnea, and several imaging studies demonstrated a 65 × 22 mm tumor in the aortopulmonary window, accompanied by massive pericardial effusion. The tumor was successfully excised with clean surgical margins under cardiopulmonary bypass, followed by patch reconstruction of the pulmonary artery, and was diagnosed as an epithelioid type of malignant pericardial mesothelioma. The patient tolerated the operation and subsequent adjuvant chemotherapy without any complications. She remained alive and asymptomatic for almost 3 years after surgery, despite the fact that the median survival of this disease is 6-10 months. This patient is the second longest postoperative survivor of this extremely rare, aggressive neoplasm.

A successful surgical repair of pulmonary stenosis caused by isolated pulmonary Takayasu's arteritis.

A 48-year-old man underwent surgery to treat pulmonary stenoses of unknown origin. The right main pulmonary artery was severely stenotic, and the orifice of the left pulmonary artery was focally constricted. The patient was nearly asymptomatic, despite marked pulmonary hypertension and right heart strain. The pressure gradients beyond the stenotic regions were 88 mmHg bilaterally. The cause of the stenoses could not be established before operation. The right main pulmonary artery and ascending aorta were successfully replaced. It was suspected that the ascending aorta was involved because it was markedly thickened and adhered tightly to the right pulmonary artery. It was therefore also replaced. However, only the transected right pulmonary artery showed histological evidence consistent with a diagnosis of Takayasu's arteritis. The postoperative course was uneventful. The patient was completely free of symptoms six months after the operation. To our knowledge, this is the thirteenth surgically treated case of isolated pulmonary Takayasu's arteritis to be reported.

Relationship between late ventricular potentials and myocardial 123I-metaiodobenzylguanidine scintigraphy in patients with dilated cardiomyopathy with mild to moderate heart failure: results of a prospective study of sudden death events.

PURPOSE: Late ventricular potentials (LPs) are considered to be useful for identifying patients with heart failure at risk of developing ventricular arrhythmias. (123)I-metaiodobenzylguanidine (MIBG) scintigraphy, which is used to evaluate cardiac sympathetic activity, has demonstrated cardiac sympathetic denervation in patients with malignant ventricular tachyarrhythmias. This study was undertaken to clarify the relationship between LPs and (123)I-MIBG scintigraphy findings in patients with dilated cardiomyopathy (DCM). METHODS: A total of 56 patients with DCM were divided into an LP-positive group (n = 24) and an LP-negative group (n = 32). During the compensated period, the delayed heart/mediastinum count (H/M) ratio, delayed total defect score (TDS), and washout rate (WR) were determined from (123)I-MIBG images and plasma brain natriuretic peptide (BNP) concentrations were measured. Left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and left ventricular ejection fraction (LVEF) were simultaneously determined by echocardiography. RESULTS: LVEDV, LVESV, LVEF and plasma BNP concentrations were similar in the two groups. However, TDS was significantly higher (35 ± 8 vs. 28 ± 6, p < 0.005), the H/M ratio was significantly lower (1.57 ± 0.23 vs. 1.78 ± 0.20, p < 0.005), and the WR was significantly higher (60 ± 14% vs. 46 ± 12%, p < 0.001) in the LP-positive than in the LP-negative group. The average follow-up time was 4.5 years, and there were nine sudden deaths among the 56 patients (16.1%). In logistic regression analysis, the incidences of sudden death events were similar in those LP-negative with WR <50%, LP-negative with WR ≥ 50% and LP-positive with WR <50% (0%, 10.0% and 14.3%, respectively), but was significantly higher (41.2%) in those LP-positive with WR ≥ 50% (p < 0.01, p < 0.05, and p < 0.05, respectively). CONCLUSION: The present study demonstrated that the values of cardiac (123)I-MIBG scintigraphic parameters were worse in LP-positive DCM patients than in LP-negative DCM patients. Furthermore, in LP-positive DCM patients with a high WR, the incidence of sudden death events was higher than that in other subgroups of DCM patients.

Is prophylactic intravenous administration of a proton pump inhibitor necessary for perioperative management of cardiac surgery?

BACKGROUND: Mortality from gastrointestinal (GI) hemorrhage caused by antiplatelet or anticoagulant therapy (or both) is quite high after cardiac surgery. We previously reported that proton pump inhibitor (PPI) therapy is indispensable in preventing postoperative GI complications. PPIs are usually administered intravenously immediately after surgery and subsequently by oral formulations. We conducted a prospective study to evaluate whether intravenous PPI followed by oral administration is more efficient as prophylaxis than oral-only administration. METHODS AND RESULTS: We enrolled 40 patients scheduled to undergo coronary artery bypass grafting with cardiopulmonary bypass and randomly assigned them to receive oral PPIs alone (group 1) or intravenous PPI followed by oral administration (group 2). Postoperative upper GI endoscopy evaluations showed no evidence of GI bleeding. Only gastritis, esophagitis, and hiatal hernia were observed at similar incidences in the groups. Mean hospital stays were also similar, but the cost of PPI treatment was significantly lower in group 1. CONCLUSION: No additional benefits of intravenous PPIs over oral formulations were demonstrated. Oral PPIs alone were effective and economical as prophylaxis against GI complications. Intravenous PPIs might be unnecessary in selected patients after cardiac surgery.

Surgical outcome of simultaneous carotid and cardiac surgery.

PURPOSE: The surgical outcome of a simultaneous carotid endarterectomy and cardiac surgery has not been clarified. This study retrospectively reviewed short- and mid-term outcomes after a carotid endarterectomy combined with valvular surgery or coronary artery bypass grafting (CABG). METHODS: Fifteen patients (12 males and 3 females, mean age 68.9 ± 6.7, range 59-86 years) underwent a carotid endarterectomy combined with cardiac surgery. The main indication for carotid endarterectomy was more than 75% carotid stenosis with or without cerebral ischemic symptom. Eight patients had a history of stroke or transient ischemic attack. Endarterectomy was performed under mild hypothermia and controlled hemodynamics with pulsatile perfusion with cardiopulmonary bypass in all cases. Concomitant cardiac procedures were aortic valve replacement in 1 patient and CABG in 14 patients. RESULTS: There was no early death. Early neurological complications occurred in only 1 patient (6.7%). The ratio of heart-type fatty acid binding protein increased significantly in those that suffered postoperative neurological complications. One patient died 6 months after the operation due to pneumonia. There was no myocardial infarction, and no events were observed in the late postoperative periods. CONCLUSIONS: Carotid endarterectomy can be safely performed in combination with cardiac surgery. Furthermore, the heat-type fatty acid binding protein levels might be useful for predicting early neurological complications.

Efficacy of prophylactic treatment with selective serotonin reuptake inhibitors for depression after open-heart surgery.

PURPOSE: The aim of the present study was to evaluate the efficacy of prophylactic treatment with selective serotonin reuptake inhibitors (SSRIs) in female patients at high risk of suffering depression after cardiac surgery. METHODS: Female patients (n = 58; group I) who were over 70 years of age or who had undergone emergency surgery were administered prophylactic treatment with paroxetine immediately after surgery. The hospital mortality and morbidity data of these patients were compared with those of 59 patients (group II) without prophylactic medication. RESULTS: The Center for Epidemiological Studies Depression Scale (CES-D) score at 10 days after surgery was significantly lower in group I (15.2 ± 7.8) than in group II (21.8 ± 7.5, P = 0.0018). The incidence of depression (I: 12.1% vs II: 64.4%, P < 0.0001) and pneumonia (I: 0% vs II: 10.2%, P = 0.0127) were significantly lower in group I than in group II. In addition, the duration of postoperative hospital stay was significantly shorter for group I than for group II (I: 15.9 ± 56.5 vs II: 23.4 ± 20.5 days, P = 0.0102). The hospital mortality rates were similar. CONCLUSION: The quality of life of patients with depression after open-heart surgery is poor. The early administration of prophylactic medication is therefore necessary for those patients at risk for developing depression.

Total arch replacement and open stent graft implantation using a newly developed stent graft: report of a case.

We experienced a case in which a total arch replacement and an open stent implantation were performed for a distal aortic arch aneurysm using a newly developed stent graft (Ube CL-0201; Ube Medical, Tokyo, Japan). This novel stent graft is composed of a woven polyester graft and a nickel-titanium alloy stent, and has been under evaluation in clinical trials at four institutions in Japan, including our hospital, since 2008. The patient was weaned from the respirator on the day after surgery, and 9 months have passed since the surgery with no complications. A follow-up computed tomography scan showed that the stent part was sufficiently open, and no complications, such as an endoleak, have been observed.

Cardiac angiosarcoma with cardiac tamponade diagnosed as a ruptured aneurysm of the sinus valsalva.

Primary cardiac angiosarcoma is a rare, diagnostically elusive disease with a poor prognosis. In this report, we describe the case of a 56-year-old woman with a right atrial angiosarcoma. The patient presented with impending cardiac tamponade caused by right atrial perforation, but was misdiagnosed as a ruptured aneurysm of the sinus valsalva based on findings of a continuous murmur and an aorta to right atrium shunt by echocardiography. In the emergent operation that ensued, we found a right atrial perforation and a right coronary artery fistula to the right atrium. Coronary artery fistula is a rare complication of primary cardiac angiosarcoma, and a continuous murmur is also extremely rare as a clinical finding of angiosarcoma. We report the case and review the literature.

First clinical application of the DuraHeart centrifugal ventricular assist device for a Japanese patient.

The DuraHeart ventricular assist device (VAD) is a third-generation implantable centrifugal pump with a magnetically levitated impeller. Since February 2007, the device has been clinically applied with excellent results as a bridge to heart transplantation in Europe. As of this writing, however, the device has yet to be approved by the Ministry of Health, Labour and Welfare for clinical use in Japan. We herein report the first clinical application of this device for a Japanese patient. A 31-year-old man with dilated cardiomyopathy was transferred to the Heart and Diabetes Center NRW (HDZ-NRW) in Bad Oeynhausen, Germany, where he was to await heart transplantation. The transfer was safely completed under management with low-dose dopamine. His condition gradually deteriorated at HDZ-NRW, and the DuraHeart left ventricular assist device was implanted for the left ventricle at 7 weeks after admission. Shortly thereafter, however, on POD 7, a Thoratec VAD had to be inserted on the right side due to refractory right heart failure. The right ventricular assist device could be explanted after a 3-month assist, and the patient is now waiting for heart transplantation at home in Germany.

Less invasive quick replacement of the proximal arch with aggressive rapid rewarming for type A acute aortic dissection.

We describe a newly modified technique, which we term "less invasive quick replacement" (LIQR) for type A acute aortic dissection (AAD). After cooling to a rectal temperature of 28 degrees C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass (CPB) circuit was warmed up to 40 degrees C during open distal anastomosis. As soon as the distal anastomosis was completed, rapid rewarming was initiated by perfusing blood at 40 degrees C. The average CPB and total operative times were 71.8 +/- 9.6 and 130.6 +/- 7.7 min, respectively. The shortest operative time was 101 min from skin incision to skin closure. All patients were weaned off the ventilator within 12 h of surgery. The postoperative hospital stay was 9.3 +/- 1.2 days. There was no incidence of cerebral damage or hospital mortality. Our initial results showed LIQR to be safe and effective.

A transesophageal echocardiographic and cine-fluoroscopic evaluation of an ATS prosthetic valve opening.

PURPOSE: The effectiveness of the ATS valves includes their durability and the quietness of the valve sound. However, a cine-fluoroscopic study revealed an incomplete opening of the valve leaflet. An overall evaluation of the ATS valve was conducted by transesophageal echocardiography. METHODS: The patients were divided into two groups based on the opening angle (OA): Group A, with a maximum OA of 80 degrees or greater and Group B, with a maximum OA of under 80 degrees. RESULTS: In Group A, the peak pressure gradient (PPG) sites of the anterior, central and posterior mitral commissure were 8.17, 8.05, and 8.09 mmHg, respectively, with no significant differences among the three sites. Similar results were obtained for Group B; the PPG at the three respective measurement sites were 8.59, 8.43, and 8.51 mmHg, and the differences were not statistically significant. No statistically significant differences were observed in the mean pressure gradient or pressure half time among the three measurement sites or between the two patient groups. CONCLUSION: Although, in many cases, the ATS valves did not open completely, the incomplete valve opening did not pose any problems in the valve function itself or in the cardiac functions of the patients.

Successful treatment of fulminant myocarditis with mechanical circulatory support.

A 66-year-old man with acute fulminant myocarditis was supported by a left ventricular assist device (LVAD) for 22 days, and successfully recovered from severe heart failure. Prior to this, he was treated using percutaneous cardiopulmonary support (PCPS) for five days. However, cardiac function was not recovered, so we conducted implantation of the LVAD. It is essential to make an immediate decision regarding LVAD implantation to save patients with fulminant myocarditis.

Vascular protecting effect of angiotensin receptor blocker (ARB) on the radial artery graft.

PURPOSE: We hypothesized that the vascular protecting effect of an angiotensin receptor blocker (ARB) reduced endothelial damage of the radial artery (RA) after coronary bypass and conducted a comparative study. PATIENTS AND METHODS: One hundred and sixty four patients were divided into the following two groups, Group C: 92 subjects who were orally administered Candesartan 8 mg/day, Group I: 72 subjects who were administered Imidapril at 5 mg/day. Graft angiography was performed one year after surgery and the RA intima was evaluated using an angioscope. RESULTS: Total cholesterol of Group C was 151.4+/-66.9 mg/dL, which was significantly lower than in Group I (182.2+/-27.8 mg/dL), and LDL cholesterol of the ARB-treated group, i.e., Group C was 96.1+/-32.5 mg/dL and significantly lower than in Group I (139.1+/-48.7 mg/dL). In angioscopy, yellow plaque was detected in the proximal RA in 7 (8.0%) and 8 (11.6%) patients of the Groups C and I, respectively, showing a lower tendency in the ARB-treated group. CONCLUSIONS: The results of evaluation one year after surgery revealed no significant difference in effects on the RA endothelium between ARB and ACE inhibitor. ARB reduced cholesterol and its effect was confirmed with blood examination data and endoscopic findings.

Coronary sinus dissection during left ventricular pacing electrode implantation.

Coronary sinus (CS) dissection during biventricular pacing electrode implantation is a complication that rarely develops. A 71-year-old female with recurrent ventricular tachycardia, heart decompensation, and poor left ventricular function because of dilated cardiomyopathy was admitted for the implantation of a cardioverter-defibrillator for biventricular pacing. During the operation, we experienced a CS dissection with hematoma in the left ventricle wall while introducing the guidance catheter into the CS. However, the pacing lead was successfully implanted into the posterolateral vein using the "over-the-wire" technique. The postoperative electrocardiogram showed a decreased QRS; meanwhile, the echocardiography revealed dimensional reduction and functional improvement of the left ventricle.

Prophylactic reoperation after mitral valve replacement with the Starr-Edwards ball valve: a report of four cases.

PURPOSE: The Starr-Edwards ball valve was first applied clinically in 1960. In our hospital, this valve has been used since 1963, and some patients have been followed up for 30 years or more. Based on our experience, therapeutic strategies included revalve replacement as a preventive procedure in the absence of valve-related complications. In this study, we investigated whether prophylactic reoperation after valve replacement with the Starr-Edwards ball valve is appropriate. PATIENTS AND METHODS: Of 58 patients in our institute who underwent mitral valve replacement with the Starr-Edwards ball valve, 12 underwent revalve replacement. Of these 12, the subjects of the present study were 4 patients who underwent prophylactic revalve replacement. RESULTS: The mean postoperative follow-up of the 4 patients was 31.0+/-3.7 years. There were no operative deaths or postoperative complications. On examination of the extirpated Starr-Edwards valves, cloth wear was observed in all 4 patients. Although there was no influence on the range of ball motion, they showed the entity of "thrombus/pannus." CONCLUSION: In this study, all of the patients showed cloth wear in the absence of complications. Therefore we consider that prophylactic reoperation after valve replacement with the Starr-Edwards valve should be performed to prevent complications.

Child with fulminant myocarditis survived by ECMO Support--report of a child case.

A 6-year-old girl had cold-like symptoms. Administration of antibiotics did not improve the symptoms, and the patient had chronic chest pain. Electrocardiogram (ECG) demonstrated ventricular tachycardia (VT) and cardiac enzyme levels were increased. Mexiletine and olprinone were continuously administered, but slow VT and III degrees A-V block repeatedly occurred. Pulse therapy using methyl prednisolone was performed, but hemodynamics did not improve. Ejection fraction (EF) decreased to 20%, and metabolic acidosis occurred. Extra corporeal membrane oxygenation (ECMO) was applied 24 hours after admission to the intensive care unit (ICU). To apply ECMO, a median sternotomy was performed. An in-flow cannula (15 Fr) was inserted into the ascending aorta and an out-flow cannula (19 Fr) was inserted into the right atrium. After returning to the ICU, blood pressure (BP) were stable, and urine volume was maintained at about 100 ml/h. Methyl prednisolone and gamma-globulin were administered during circulatory assisted period. About 24 hours later, sinus rhythm was obtained, and weaning was started after improvement of the EF. BP was maintained at 100 mmHg with low dose catecholamine, which was weaned off 42 hours after commencement. Hemodynamics after this remained stable. EF improved to 54.2%. An ECG demonstrated right bundle branch block (RBBB) at the sinus rhythm. Severe inflammatory changes were pathologically observed, and we diagnosed myocarditis. The patient was discharged from the hospital on 43 days post admission, and currently attends school.

A surgical case of left ventricular pseudoaneurysm complicating myocardial infarction in a diabetic patient on dialysis.

A 57-year-old man was hospitalized with dyspnea and heart failure. We performed an electrocardiogram, coronary angiogram, echocardiogram, and magnetic resonance imaging. He was diagnosed with a left ventricular pseudoaneurysm (i.e., heart tumor) at the posterolateral wall. Minimal contrast medium was utilized when making the diagnosis as the patient was on dialysis. We subsequently repaired the ventricular unruptured pseudoaneurysm and performed a coronary artery bypass grafting. This case presented difficulty in ascertaining the difference between a cardiac tumor and a ventricular pseudoaneurysm.

[Cardiac surgery in Japan from a view of Germany].

In Germany, standards of facilities for cardiovascular surgery are established under the guidance of the Ministry of Health and Welfare, and numbers of hospitals are regulated for the needs of patients. Not only in Germany but in many countries of Europe, it is reasonable by a number of patients 1 to 1 million population. A number of cardiac operations in 1 authorized institution in Germany is 10 times as that of Japan. In this condition, I'll introduce the medical care systems of Germany; postgraduate education system for both medical specialists and home doctors, introduction of private insurance system based on National Health Insurance system for everyone, and a release of medical information, quality control, acknowledged not by an own declaration but by the third organization.