Short- and long-term performance of risk calculation tools for mortality in patients with acute coronary syndrome.

Background: The mortality rate of acute coronary syndrome (ACS) remains high. Therefore, patients with ACS should undergo early risk stratification, for which various risk calculation tools are available. However, it remains uncertain whether the predictive performance varies over time between risk calculation tools for different target periods. This study aimed to compare the predictive performance of risk calculation tools in estimating short- and long-term mortality risks in patients with ACS, while considering different observation periods using time-dependent receiver operating characteristic (ROC) analysis. Methods: This study included 404 consecutive patients with ACS who underwent coronary angiography at our hospital from March 2017 to January 2021. The ACTION and GRACE scores for short-term risk stratification purposes and CRUSADE scores for long-term risk stratification purposes were calculated for all participants. The participants were followed up for 36 months to assess mortality. Using time-dependent ROC analysis, we evaluated the area under the curve (AUC) of the ACTION, CRUSADE, and GRACE scores at 1, 6, 12, 24, and 36 months. Results: Sixty-six patients died during the observation periods. The AUCs at 1, 6, 12, 24, and 36 months of the ACTION score were 0.942, 0.925, 0.889, 0.856, and 0.832; those of the CRUSADE score were 0.881, 0.883, 0.862, 0.876, and 0.862; and those of the GRACE score 0.949, 0.928, 0.888, 0.875, and 0.860, respectively. Conclusions: The ACTION and GRACE scores were excellent risk stratification tools for mortality in the short term. The prognostic performance of each risk score was almost similar in the long term, but the CRUSADE score might be a superior risk stratification tool in the longer term than 3 years.

Temperature imaging inside fluid devices using a ratiometric near infrared (NIR-II/III) fluorescent Y2O3: Nd3+, Yb3+, Er3+ nanothermometer.

Luminescence thermometry is a non-contact method that can measure surface temperatures and the temperature of the area where the fluorescent probe is located, allowing temperature distribution visualizations with a camera. Ratiometric fluorescence thermometry, which uses the intensity ratio of fluorescence peaks at two wavelengths with different fluorescence intensity dependencies, is an excellent method for visualizing temperature distributions independent of the fluorophore spatial concentration, excitation light intensity and absolute fluorescence intensity. Herein, Nd3+/Yb3+/Er3+-doped Y2O3 nanomaterials with a diameter of 200 nm were prepared as phosphors for temperature distribution measurement of fluids at different temperatures. The advantages of this designed fluorescent material include non-aggregation in water and the fact that its near-infrared (NIR) fluorescence excitation (808 nm) is not absorbed by water, thereby minimizing sample heating upon irradiation. Under optical excitation at 808 nm, the ratio of the fluorescence intensities of Yb3+ (IYb; 975 nm) and Er3+ (IEr; 1550 nm), which exhibited different temperature responses, indicated the temperature distribution inside the fluid device. Thus, this technique using Nd3+/Yb3+/Er3+-doped Y2O3 is expected to be applied for temperature distribution mapping analysis inside fluidic devices as a ratiometric NIR fluorescence thermometer, which is unaffected by laser-induced heating.

Pleurodesis using OK-432 for persistent pleural effusion after cardiac surgery in the neonatal period or early infancy.

OBJECTIVE: To evaluate the efficacy of pleurodesis using OK-432 after cardiac surgery in the neonatal period or early infancy. METHODS: We retrospectively reviewed the data of 11 consecutive patients who underwent cardiac surgery in the neonatal period or early infancy and pleurodesis using OK-432 for persistent postoperative pleural effusion in two institutions. RESULTS: The median age at surgery was 8 days (interquartile range [IR], 2-18) with a body weight of 2.84 kg (IR, 2.30-3.07). The maximum amount of pleural drainage before pleurodesis was 94.7 (IR, 60.2-107.7) ml/kg/day. Pleurodesis was initiated at postoperative day 20 (IR, 17-22) and performed in bilateral pleural spaces in seven patients and unilateral in four. The median numbers of injection were 4 (IR, 3-6) times per patient and 3 (IR, 2-3) times per pleural space. In 10 patients, pleural effusion was decreased effectively, and drainage tubes were removed without reaccumulation within 15 (IR, 12-28) days after initial pleurodesis. However, in one patient, with severe lymphedema, pleural effusion was uncontrollable, resulting in death due to sepsis. Adverse events were observed in nine patients; temporal deterioration of lung compliance and arterial blood gas occurred in two, insufficient drainage requiring new chest tube(s) in five, temporal atrial tachyarrhythmia in one, and lymphedema in four. CONCLUSIONS: Pleurodesis using OK-432 is effective and reliable for persistent postoperative pleural effusion in neonates and early infants. Most of the complications, which derived from inflammatory reactions, were temporary and controllable. However, severe lymphedema is difficult to control.

Primary sutureless repair concomitant with the Warden procedure.

A 2-month-old girl who had supracardiac total anomalous pulmonary venous connection (Darling classification type 1b) was referred to our institution. Computed tomography showed that multiple right upper pulmonary veins drained into the vertical vein, near the entry to the superior vena cava. The common pulmonary venous chamber was located lower right than usual, and right upper pulmonary veins were far from the common chamber. We successfully performed primary sutureless repair concomitant with the Warden procedure. Postoperative computed tomography showed unobstructed pulmonary veins and superior vena cava routes, and the vertical vein between right upper and lower pulmonary veins shrank slightly.

Paediatric Takayasu's arteritis complicated by thrombotic occlusion of the distal thoracic aorta.

We present the case of a 1-year-old girl with mid-aortic syndrome due to untreated Takayasu's arteritis who developed cardiogenic shock. Enhanced computed tomography revealed long-segment occlusion of the distal thoracic aorta. We successfully performed graft interpose (10 mm in diameter) under cardiopulmonary bypass through both median sternotomy and left posterolateral thoracotomy. The thrombus was relatively small and the distal thoracic aorta was narrow over a long segment due to severely thickened intima. Follow-up computed tomography showed widely patent graft without a stenotic region in the abdominal aorta or its branches. The patient discharged ambulatory without major complications.

Damus-Kay-Stansel procedure with ventricular septal defect enlargement.

A full-term infant who had tricuspid atresia with transposed great arteries, a ventricular septal defect, subpulmonary stenosis with posterior malalignment of the conus septum, bicuspid pulmonary valve, and a high-takeoff left coronary artery was referred to our institution. The subpulmonary stenosis gradually progressed and cyanosis worsened. We successfully performed a Damus-Kay-Stansel procedure and a bidirectional Glenn shunt concomitant with ventricular septal defect enlargement. The conus septum was resected along with thick fibrous tissue through both semilunar valves (without ventriculotomy). Postoperative echocardiography demonstrated that both the ventricular septal defect and the subpulmonary space were enlarged effectively without semilunar valve regurgitation.

A case of severe aortic stenosis caused by unicuspid unicommissural aortic valve.

Unicuspid aortic valve (UAV) is an extremely rare congenital malformation that frequently presents with valvular dysfunction or aortic aneurysm. Here we report the case of a 49-year-old man with severe aortic stenosis caused by UAV requiring the Bentall procedure. Two- and three-dimensional transesophageal echocardiography revealed an eccentric opening in an aortic valve and a lateral attachment to the aorta at the orifice level, suggestive of which is consistent with unicommissural UAV as confirmed by surgical findings. .

Hypothermic effects on gas exchange performance of membrane oxygenator and blood coagulation during cardiopulmonary bypass in pigs.

INTRODUCTION: Whether hypothermic cardiopulmonary bypass could attenuate both blood coagulation and platelet activation compared to normothermic cardiopulmonary bypass remains elusive. METHODS: Biocompatibility of a polymer-coated cardiopulmonary bypass circuit was comparatively assessed by plasma proteomics between juvenile pigs undergoing hypothermic (23°C) cardiopulmonary bypass and those undergoing normothermic (37°C) cardiopulmonary bypass (n = 6, respectively). Plasma samples were taken three times: 5 minutes after initiation of cardiopulmonary bypass (T5, before cooling), just before declamping and rewarming (Tc), and just before termination of cardiopulmonary bypass (Trw, 120 minutes). Proteomic analysis was quantitively performed by isobaric tags for relative and absolute quantification labeling. Thrombin-antithrombin complexes (TAT III) were measured by enzyme immunoassay, and vitamin K-dependent protein C (PROC), ß-thromboglobulin (TG), and P-selectin were measured by enzyme-linked immunosorbent assay. Blood gas analyses evaluated oxygenator performance. RESULTS: Hypothermic cardiopulmonary bypass had a significantly higher PaO2 at Tc and lower PaCO2 at Trw than normothermic cardiopulmonary bypass. Two hundred twenty-four proteins were identified with statistical criteria of both protein confidence (>95%) and false discovery rate (<5%). Six of these proteins significantly decreased at Tc than at T5 in hypothermic cardiopulmonary bypass (p = 0.02-0.04), with three related to platelet degranulation. Protein C decreased at Trw compared with T5 in normothermic cardiopulmonary bypass (p = 0.04). Thrombin-antithrombin complex had a slightly larger increase with normothermic cardiopulmonary bypass at Trw than with hypothermic cardiopulmonary bypass. ß-thromboglobulin and P-selectin levels were significantly lower at Trw with hypothermic cardiopulmonary bypass than with normothermic cardiopulmonary bypass (p = 0.04). CONCLUSION: Hypothermic cardiopulmonary bypass attenuated platelet degranulation/blood coagulation and maintained better oxygenator performance compared to normothermic cardiopulmonary bypass in juvenile pigs.

Plasma proteomic changes during therapeutic hypothermia in resuscitated patients after cardiac arrest.

Hypothermia is used for several h during cardiac and aortic surgery to protect ischemic organs. Therapeutic hypothermia (TH) is used for ≤24 h as a treatment for comatose patients after the return of spontaneous circulation (ROSC) following cardiac arrest. The proteomic approach may provide unbiased data on alterations in the abundance of proteins during TH. The objective of this study was to assess the effects of cooling/rewarming on the plasma proteome during TH after ROSC and to identify the mechanism underlying its therapeutic effects. A total of nine comatose adult patients, resuscitated shortly after cardiac arrest, were cooled to 34°C for 24 h and slowly rewarmed to 36°C. A quantitative gel-free proteomic analysis was performed using the isobaric tag for relative and absolute quantification labeling tandem mass spectrometry. Plasma samples were obtained prior to cooling and rewarming, and immediately after rewarming, from all patients during TH after ROSC. A total of 92 high-confidence proteins were identified. Statistically significant alterations were observed (>1.2-fold increase or <0.833-fold decrease) in the levels of 15 of those proteins (P=0.003-0.047), mainly proteins belonging to the acute-phase response or platelet degranulation. Unexpectedly, the levels of free hemoglobin (hemoglobin subunits α and ß) were significantly downregulated during TH (P<0.05). The level of the terminal complement complex (SC5b-9) showed significant reduction after cooling (P=0.023). Although the acute-phase response proteins were upregulated, the abundance of complement proteins did not change, and the levels of SC5b-9 and free hemoglobin decreased during TH in patients after ROSC.

Outcome From a Randomized Controlled Clinical Trial　- Improvement of Peripheral Arterial Disease by Granulocyte Colony-Stimulating Factor-Mobilized Autologous Peripheral-Blood-Mononuclear Cell Transplantation (IMPACT).

BACKGROUND: The clinical usefulness of peripheral blood (PB) mononuclear cell (MNC) transplantation in patients with peripheral arterial disease (PAD), especially in those with mild-to-moderate severity, has not been fully clarified.Methods and Results:A randomized clinical trial was conducted to evaluate the efficacy and safety of granulocyte colony-stimulating factor (G-CSF)-mobilized PBMNC transplantation in patients with PAD (Fontaine stage II-IV and Rutherford category 1-5) caused by arteriosclerosis obliterans or Buerger's disease. The primary endpoint was progression-free survival (PFS). In total, 107 subjects were enrolled. At baseline, Fontaine stage was II/III in 82 patients and IV in 21, and 54 patients were on hemodialysis. A total of 50 patients had intramuscular transplantation of PBMNC combined with standard of care (SOC) (cell therapy group), and 53 received SOC only (control group). PFS tended to be improved in the cell therapy group than in the control group (P=0.07). PFS in Fontaine stage II/III subgroup was significantly better in the cell therapy group than in the control group. Cell therapy-related adverse events were transient and not serious. CONCLUSIONS: In this first randomized, large-scale clinical trial of G-CSF-mobilized PBMNC transplantation, the cell therapy was tolerated by a variety of PAD patients. The PBMNC therapy was significantly effective for inhibiting disease progression in mild-to-moderate PAD.

Improvement of the Left Ventricular Function after Tricuspid Valve Plasty for Traumatic Tricuspid Regurgitation.

Traumatic tricuspid regurgitation (TR) is a rare cardiovascular complication in chest trauma. Changes in the left ventricle (LV) function after operation are unclear. A 61-year-old woman who had been involved in a traffic accident 1 month earlier presented with exertional dyspnea. Transthoracic echocardiography (TTE) showed severe tricuspid regurgitation (TR) accompanied by LV dysfunction due to anterior leaflet prolapse with papillary muscle rupture. After tricuspid plasty, the LV function improved, as evidenced by TTE and speckle tracking echocardiography. In conclusion, the early diagnosis of traumatic TR is important, and early surgical intervention might be effective for achieving ventricular function improvement.

Recovery from very long aortic cross-clamping in redo complex aortic surgery.

A 68-year-old man had undergone ascending aortic replacement for acute type A aortic dissection. Three months later, he had a new aortic dissection with an ulcer-like projection located in the aortic arch with suspected graft infection. An emergent redo total aortic arch and root replacement was performed because of the coexistence of a fragile aortic root wall. The extensive redo procedure necessitated a very long aortic cross-clamping time (516 min). After 25 min of assisted circulation, he was easily weaned from the cardiopulmonary bypass. Finally, an omental flap was harvested to cover the graft. Postoperative ECG and CK-MB examinations showed no significant myocardial injury. He had no symptoms of heart failure and was discharged after a month of antibiotic therapy. One-year follow-up UCG study revealed no abnormal findings except for signs of pericardial adhesion.

Polymer-coated cardiopulmonary bypass circuit attenuates upregulation of both proteases/protease inhibitors and platelet degranulation in pigs.

INTRODUCTION: Interaction of blood with a cardiopulmonary bypass (CPB) circuit activates the coagulation-fibrinolysis, complement and kinin-kallikrein systems that are mainly supported by proteases and their inhibitors. METHODS: Biocompatibility of a new polymer-coated (SEC-coated) CPB circuit was globally evaluated and compared with that of a non-coated CPB circuit by quantitative proteomics, using isobaric tags for relative and absolute quantification labeling tandem mass spectrometry. Plasma samples were taken three times (5 min after initiation of CPB, just before declamping and just before termination of CPB) in 12 pigs undergoing 120 min of CPB with the SEC-coated CPB circuit or a non-coated CPB circuit (n = 6, respectively). RESULTS: Identified were 224 proteins having high protein confidence (>99%) and false discovery rate (FDR) <5%. Among these proteins, there were 25 significantly upregulated proteins in the non-coated CPB group compared to those in the SEC-coated CPB group. Dominant protein functions were platelet degranulation, serine-type (cysteine-type) endopeptidase inhibitor activity and serine-type endopeptidase activity in the 25 proteins. Bioinformatics analysis similarly revealed upregulation of proteins belonging to platelet degranulation and negative regulation of endopeptidase activity in the non-coated CPB group; these upregulations were effectively attenuated in the SEC-coated CPB group. CONCLUSION: The new polymer (SEC)-coated CPB circuit effectively attenuated upregulation of proteins compared to the non-coated CPB circuit. These proteins were associated with both proteases/protease inhibitors and platelet degranulation.

A case of staged Norwood procedure for a unique form of truncus arteriosus, interrupted aortic arch with hypoplastic tricuspid valve and right ventricle and anomalous left coronary artery orifice: first reported case.

We present the first reported case of truncus arteriosus, interrupted aortic arch with hypoplastic tricuspid valve and right ventricle and anomalous left coronary artery orifice in a neonate in whom successful palliation was performed using two-staged procedure. The first-stage palliation was the bilateral pulmonary artery band at age 2 days. The second-stage palliation was a Norwood procedure concomitant with ASD creation and patch augmentation of the pulmonary artery confluence at 22 days. The patient is doing well, with unobstructed aortic arch and mild truncal valve regurgitation.

[Influence of an Operative Strategy on Outcomes of Acute Type A Aortic Dissection Cases].

OBJECTIVE: To compare the surgical outcomes of total arch replacement with the outcomes of ascending aorta replacement in patients with acute Stanford type A aortic dissection. METHODS: From April 2002 to May 2014, 90 patients with acute Stanford type A aortic dissection underwent emergency surgical treatment at our institution. Among them, 16 underwent total arch replacement and 74 underwent ascending aorta replacement. The decision to perform total arch versus ascending aorta replacement was dependent on an intimal tearing site. RESULTS: There were no statistically significant differences in characteristics between the groups with regard to the 2 surgical procedures. Twenty early deaths were reported, but there was no statistically significant difference in mortality rate between the groups. The aortic operation had to be redone in 12 patients. The reoperations were not associated with an increased risk of death or neurological complications. Overall 5-year survival rates were 68% in the ascending aorta replacement group and 59% in the total arch replacement group. There was no statistically significant difference between the groups. CONCLUSIONS: The surgical outcome and prognosis of ascending aorta replacement is satisfactory among patients undergoing treatment of acute type A aortic dissection.

Proteomic analysis in cardiovascular research.

Advances in mass spectrometry technology and bioinformatics using clinical human samples have expanded quantitative proteomics in cardiovascular research. There are two major proteomic strategies: namely, "gel-based" or "gel-free" proteomics coupled with either "top-down" or "bottom-up" mass spectrometry. Both are introduced into the proteomic analysis using plasma or serum sample targeting 'biomarker" searches of aortic aneurysm and tissue samples, such as from the aneurysmal wall, calcific aortic valve, or myocardial tissue, investigating pathophysiological protein interactions and post-translational modifications. We summarize the proteomic studies that analyzed human samples taken during cardiovascular surgery to investigate disease processes, in order to better understand the system-wide changes behind known molecular factors and specific signaling pathways.

Senning operation for very low birth weight infant with transposition of the great arteries: one of the smallest cases in the world.

We report a case of a Senning operation for very low birth weight infant weighing 1,168 g with transposition of the great arteries. The patient underwent a Senning operation on 62 days, 1,700 g after the first palliation. In this case, the orifice of the left anterior descending artery was located in sinus 1 (left posterior facing sinus), but we could not find orifices of both right coronary artery and left circumflex artery before the Senning operation. The surgical procedure of the Senning operation is typical one, but we used flesh autopericardial patch to cover the roof of the new pulmonary vein chamber to get an enough size. The patient recovered with no cardiac events after the repair.

Does the Rewarmed Heart Restore the Myocardial Proteome to That of the Pre-Cooled State?--A Proteomic Analysis of Surgical Samples.

BACKGROUND: Hypothermia is utilized in cardiac and aortic surgery to protect organs from ischemic reperfusion injury. Although the cooled body is invariably rewarmed after the procedure, it is still unknown whether the rewarmed body regains its former biological state. This study determined the modulatory effects of hypothermia on the human myocardial proteome and whether subsequent rewarming restores the proteome to the state prior to cooling. METHODS AND RESULTS: A quantitative proteomic analysis was performed using isobaric tags for relative and absolute quantification labeling tandem mass spectrometry. Right atrial samples were taken 3 times (pre, during and post cooling) during deep hypothermic cardiopulmonary bypass (CPB) from 8 patients with aortic arch aneurysms and 3 corresponding time points during normothermic CPB from 8 patients with ascending aortic or valsalva aneurysms. In total, 697 proteins were identified, with 222 proteins having high protein confidence. Bioinformatic analyses revealed significant downregulation of 19 proteins associated with energy production at hypothermic cardioplegic arrest. On rewarmed beating, 10 proteins remained downregulated, including those regulating cardiac contraction and adaptor proteins, although levels of the aforementioned 19 downregulated proteins returned to their initial values. Additional echocardiographic evaluation demonstrated that hypothermia preserved the variables of diastolic function to a greater extent than normothermic surgery. CONCLUSIONS: Rewarming restores the human myocardial proteome to the pre-cooled state, except for proteins regulating cardiac contraction and adaptor proteins.

Monitoring of Serial Presurgical and Postsurgical Changes in the Serum Proteome in a Series of Patients with Calcific Aortic Stenosis.

BACKGROUND: Comprehensive analysis of proteome differentially expressed in response to surgery or drug treatment is useful to understand biological responses to dispensed interventions. Here we investigated expression changes in sera of patients who suffered from calcific aortic stenosis (CAS), before and after surgery for aortic valve replacement. MATERIALS AND METHODS: Sera obtained before and after surgery with depletion of highly abundant proteins were analyzed with iTRAQ labeling followed by nanoLC-MALDI-TOF/TOF-MS/MS. RESULTS: Fifty-one proteins shared in five patients were identified with differential levels in postsurgical and presurgical sera. Finally, 16 proteins that show statistically significant levels in patients' sera compared with those in control sera (P < 0.05) were identified. Most of the identified proteins were positive acute-phase proteins. Among three proteins other than acute-phase proteins, we confirmed increased levels of antithrombin-III and zinc-α-2-glycoprotein in postsurgical sera by Western blot analysis using other CAS patients' sera. Furthermore, antithrombin-III and zinc-α-2-glycoprotein were not found among proteins with differential levels in postsurgical and presurgical sera of patients with aortic aneurysms that we identified in a previous study. CONCLUSIONS: The results indicated that antithrombin-III and zinc-α-2-glycoprotein would become unique monitoring proteins for evaluating pathophysiological and biochemical processes occurring before and after surgery for CAS.

[Strategies for lung cancer with ischemic heart disease].

For lung cancer surgery which merged ischemic heart disease to need coronary artery treatments, the strategy is demanded on the timing of each treatment. Our department conforms to American College of Chest Physicians( ACCP) guideline and treatment strategies are decided as follows. 1) If right heart load has already occurred, we choose limited surgery for lung cancer. 2) Two-stage surgery is performed with principle. Coronary artery treatment is given priority to against left main trunk disease and unstable angina. 3) Simultaneous surgery is chosen for lung cancer more than stage II or lung cancer pressing neighboring organ and vessel not to be able to wait coronary artery treatments. Since 2007, we performed 4 simultaneous surgeries and experienced 3 pneumonia cases, 1 patient died in 5 months. We must decide a strategy in consideration of progress of the lung cancer and cardiac urgency.