Twisting of HeartMate II outflow graft 2.5 years after implantation-HM2 is still ongoing.

A 47-year-old woman with dilated cardiomyopathy underwent HeartMate II (HM2) implantation as a bridge-to-transplantation. Her postoperative course was good. However, 2.5 years after surgery, the outflow graft was found to be twisted and the graft and pump was exchanged. While HeartMate 3(HM3) twisting of the outflow graft is well documented, such malfunctions in HM2 are almost unknown. Although HM2 has since been discontinued, there are a significant number of patients using HM2 who are awaiting heart transplants or destination therapy. We caution that, even with HM2, the possibility of late-phase twisting requires vigilance.

Aortic valve area index values of Trifecta implants correlate with energy loss and increased valve stress.

Biological valves are becoming more frequently used in aortic valve replacement. While several reports have evaluated the performance of biological valves, echocardiography studies during exercise stress remain scarce. Furthermore, no current reports compare rate changes in the aortic valve area of biological valves under increased exercise load. Here, we performed exercise stress echocardiography in patients after AVR with Trifecta or Inspiris valves and compared the rates of change in aortic valve areas (AVA). In addition, hydrodynamic analysis at rest was conducted with four-dimensional flow magnetic resonance imaging (4D-flow MRI). Exercise stress echocardiography was performed in seven Trifecta and seven Inspiris patients who underwent AVR at our hospital while 4D flow MRI was performed in all but two Trifecta cases. Comparing the percentage change in AVA when loaded to 25 W versus at rest, Trifecta was greater than Inspiris (28.7 ± 36.0 vs - 0.8 ± 12.4%). The smaller AVA at rest was considered causative for this. Meanwhile, Trifecta systolic energy loss in the prosthetic valve segment on 4D-flow MRI (97.5 ± 35.9 vs 52.7 ± 25.3 mW) was higher than Inspiris. The opening of the Trifecta valve was considered to be restricted at rest and this may reflect the current reports of early valve degradation requiring reoperation. Taken together, we observed that the Trifecta design may promote faster wear due to higher valve stress.

Differences in the components of metabolic syndrome by age and sex: a cross-sectional and longitudinal analysis of a cohort of middle-aged and older Japanese adults.

BACKGROUND: The prevalence of metabolic syndrome (MetS) in Japan, a super-aged society, is increasing and poses a major public health issue. Several studies have reported sex differences in the association between age and MetS prevalence. This study aimed to examine the association between age and the prevalence of MetS based on multiple screening criteria and MetS components by sex. METHODS: We used 6 years of individual-level longitudinal follow-up data (June 2012 to November 2018; checkup year: 2012-2017) of middle-aged and older adults aged 40-75 years in Japan (N = 161,735). The Joint Interim Statement criteria, International Diabetes Federation criteria, and another set of criteria excluding central obesity were used as the screening criteria for MetS. The prevalence of MetS and MetS components was cross-sectionally analyzed according to sex and age. A longitudinal association analysis of age, MetS, and MetS components by sex was performed using a multilevel logistic model, adjusted for lifestyle- and regional-related factors. RESULTS: Sex differences were observed in the prevalence and association of MetS and MetS components. In all age groups, the prevalence of central obesity was higher among women, and the prevalence of high blood pressure and fasting glucose was higher among men (P < 0.001). The prevalence of high triglyceride and low high-density lipoprotein cholesterol was higher among women aged > 60 years (P < 0.05). Based on the criteria of the Joint Interim Statement and International Diabetes Federation, the prevalence of MetS was higher among women than in men aged > 55 years (P < 0.001). Men had a higher prevalence of MetS without central obesity than women in all age groups (P < 0.001). The odds ratio for MetS and MetS components with aging was greater among women than in men. CONCLUSIONS: Medical management should be based on the prevalence of MetS and its components according to sex and age. In particular, the high prevalence of MetS without central obesity in middle-aged and older Japanese men suggests that the adoption of the Joint Interim Statement criteria, which do not precondition central obesity, should be considered.

Myeloid Progenitor Inhibitory Factor-1 (CCL23) Inhibits Lung Leukocyte Recruitment in a Primate Cardiopulmonary Bypass-Induced Pulmonary Ischaemia Model.

BACKGROUND: Bone marrow (BM)-derived polymorphonuclear leukocytes (PMNs) and monocytes (MO) induced by cardiopulmonary bypass (CPB) are highly proteolytic and cause postoperative lung injury. Although CCL23/Myeloid progenitor inhibitory factor-1 is a human CC chemokine with potent suppressor effects on myeloid progenitor cells, in vivo inhibitory effects on BM-derived leukocyte kinetics associated with CPB are unknown. METHODS: Two-hour CPB was surgically performed in cynomolgus monkeys and BM-derived leukocytes kinetics were monitored postoperatively by flow cytometry with 5'-bromo-2'-deoxyuridine (BrdU) and cytokine ELISA. Monkeys were given CCL23 (n=5) or saline (control, n=5) intravenously daily for 3 days before BrdU labelling and peripheral blood/bronchoalveolar lavage fluid (BALF) timepoint sampling to reveal BrdU-labelled cells. Levels of cytokines, CD11b, and L-selectin were considered leukocytic activation markers. RESULTS: The CCL23 treatment significantly prolonged BM transit of leukocytes (PMNs, 118.4±11.7-95.5±4.1 hours [control]; MO, 91.6±5.0-62.0±3.0 hours [control]) and reduced their alveolar appearance. The BM pool size of MO was decreased by CCL23 but PMNs were unaffected. CD11b, L-selectin expression of PMNs and MO during CPB, and post-surgical increases of interleukin (IL)-6, IL-8, TNF-α, MCP-1, and PMN elastase in the BALF were not suppressed. CONCLUSIONS: CCL23 treatment slows turnover of PMN and MO progenitors in BM and suppresses their circulatory release and lung recruitment. CCL23 has inhibitory effects specifically on the CPB-induced BM response and could hold value for preventing CPB-induced lung injury.

Screening methods for gestational diabetes mellitus in Japan in 2018: a retrospective cohort study using a national surveillance questionnaire.

This study aimed to investigate the relationship between gestational diabetes mellitus (GDM) screening methods and GDM incidences. In 2018, a national questionnaire was administered at 231 institutions (56.6%) of all 408 perinatal medical centers in Japan. Of 100,485 women, 2,982 (3.0%) were diagnosed with GDM during their first pregnancy period (FPP) and 7,289 (7.3%) were diagnosed with GDM during their middle pregnancy period (MPP). The proportion of women diagnosed with GDM during FPP and MPP using 95 mg/dL as the cutoff value (CV) for random plasma glucose (PG) at FPP (4.3% and 9.2%) was significantly higher than that of women diagnosed with GDM using 100 mg/dL as the CV for random PG (2.7% and 6.9%, p < 0.0001, respectively). Compared with women screened for GDM using "random PG and random PG," women who were screened for GDM using "random PG and 50-g glucose challenge test (GCT)" had a significantly higher incidence of GDM (6.6% versus 8.9%, p < 0.0001). Using random PG and 50-g GCT, the incidence of GDM among women diagnosed at MPP using a CV of 95 mg/dL at FPP was significantly higher than that of women diagnosed using a CV of 100 mg/dL (16.5% versus 7.8%: p < 0.0001). While, using "random PG and random PG," the incidences of GDM among women were similar between institutions using a CV of 100 mg/dL and those using a CV of 95 mg/dL at FPP (6.7% versus 6.9%: p = 0.3581). This study showed random PG as a first-step screening method in MPP may overlook women with GDM.

Successful surgical resection plus surgical cryoablation for the treatment of a large left ventricular fibroma.

Residual tumor mass after large cardiac fibroma resection carries long-term risk, but cryoablation is useful during surgery to remove such tissue. Here, we present a case of a large cardiac fibroma of the posterior wall of the left ventricle, discovered during long-term, episodic ventricular tachycardia. Resection with cryoablation completely removed the tumor, eliminating postoperative, distant ventricular arrhythmias.

Arterial switch operation with coronary button extension and neo-pulmonary trunk realignment for a rare coronary pattern.

Coronary anatomy is key for arterial switch operations as reimplantation for coronary artery patterns originating from the same sinus is often challenging. We experienced an extremely rare coronary artery anatomy case (Leiden convention: 1 R, 1LCx) and successfully performed an arterial switch operation with coronary button extension and neo-pulmonary trunk realignment maneuver.

Pediatric cardiac tamponade caused by metallic wire penetration into the heart: A case report and literature review.

Thin, metallic wires can easily penetrate the gastrointestinal system if ingested and cause serious cardiac issues in children. We report a pediatric case of such an object that caused cardiac tamponade after lodging in the left ventricle. The wire was extracted without cardiopulmonary bypass and a full recovery was made. Cardiac issues after ingestion of foreign objects are rare but immediate surgery is required for resolution.

Endogenous and exogenous protection from surgically induced reactive oxygen and nitrogen species.

Surgical intervention creates reactive oxygen species through diverse molecular mechanisms, including direct stimulation of immune-mediated inflammation necessary for wound healing. However, dysregulation of redox homeostasis in surgical patients overwhelms the endogenous defense system, slowing the healing process and damaging organs. We broadly surveyed reactive oxygen species that result from surgical interventions and the endogenous and/or exogenous antioxidants that control them. This study assimilates current reports on surgical sources of reactive oxygen and nitrogen species along with literature reports on the effects of endogenous and exogenous antioxidants in human, animal, and clinical settings. Although exogenous antioxidants are generally beneficial, endogenous antioxidant systems account for over 80% of total activity, varying based on patient age, sex, and health or co-morbidity status, especially in smokers, the diabetic, and the obese. Supplementation of exogenous compounds for support in surgical patients is thus theoretically beneficial, but a lack of persuasive clinical evidence has left this potential patient support strategy without clear guidelines. A more thorough understanding of the mechanisms of exogenous antioxidants in patients with compromised health statuses and pharmacokinetic profiling may increase the utility of such support in both the operating and recovery rooms.

Right Ventricular Outflow Tract Myxoma with Absent Pulmonary Valve.

Myxoma is the most common benign cardiac tumor. Absent pulmonary valves, often treated surgically in childhood, are associated with 3-6% of tetralogy of Fallot. It is unusual for absent pulmonary valves without other congenital heart diseases to be asymptomatic until adulthood. Here, we report the unique case of an 80-year-old female with right ventricular outflow tract myxoma and absent pulmonary valve that has, to our knowledge, never been reported. We successfully performed a simple mass resection and pulmonary valve implantation.

Factors of Obesity and Metabolically Healthy Obesity in Asia.

The East Asian region (China, Japan, and South Korea) is comprised of almost 1.5 billion people and recent industrialization has brought with it a pandemic of rising obesity, even in children. As these countries are rapidly aging and functioning at sub-replacement birthrates, the burgeoning costs of obesity-related care may threaten socialized healthcare systems and quality of life. However, a condition called metabolically healthy obesity (MHO) has been found to be without immediate cardiopulmonary or diabetic risk. Thus, maintenance of the MHO condition for the obese in East Asia could buffer the burden of long-term obesity care on medical systems and knowledge of the biochemical, genetic, and physiological milieu associated with it could also provide new targets for intervention. Diverse physiological, psychological, environmental, and social factors play a role in obesogenesis and the transition of MHO to a metabolically unhealthy obesity. This review will give a broad survey of the various causes of obesity and MHO, with special emphasis on the East Asian population and studies from that region.

Role of PAR1-Egr1 in the Initiation of Thoracic Aortic Aneurysm in Fbln4-Deficient Mice.

OBJECTIVE: Remodeling of the extracellular matrix plays a vital role in cardiovascular diseases. Using a mouse model of postnatal ascending aortic aneurysms (termed Fbln4SMKO), we have reported that abnormal mechanosensing led to aneurysm formation in Fbln4SMKO with an upregulation of the mechanosensitive transcription factor, Egr1 (Early growth response 1). However, the role of Egr1 and its upstream regulator(s) in the initiation of aneurysm development and their relationship to an aneurysmal microenvironment are unknown. Approach and Results: To investigate the contribution of Egr1 in the aneurysm development, we deleted Egr1 in Fbln4SMKO mice and generated double knockout mice (DKO, Fbln4SMKO; Egr1-/-). Aneurysms were prevented in DKO mice (42.8%) and Fbln4SMKO; Egr1+/- mice (26%). Ingenuity Pathway Analysis identified PAR1 (protease-activated receptor 1) as a potential Egr1 upstream gene. Protein and transcript levels of PAR1 were highly increased in Fbln4SMKO aortas at postnatal day 1 before aneurysm formed, together with active thrombin and MMP (matrix metalloproteinase)-9, both of which serve as a PAR1 activator. Concordantly, protein levels of PAR1, Egr1, and thrombin were significantly increased in human thoracic aortic aneurysms. In vitro cyclic stretch assays (1.0 Hz, 20% strain, 8 hours) using mouse primary vascular smooth muscle cells induced marked expression of PAR1 and secretion of prothrombin in response to mechanical stretch. Thrombin was sufficient to induce Egr1 expression in a PAR1-dependent manner. CONCLUSIONS: We propose that thrombin, MMP-9, and mechanical stimuli in the Fbln4SMKO aorta activate PAR1, leading to the upregulation of Egr1 and initiation of ascending aortic aneurysms.

An autopsy case of aortic dissection due to giant cell arteritis.

Giant cell arteritis (GCA) is a systemic vasculitis affecting mainly large and medium-sized arteries. GCA sometimes involves the aorta and its major branches and causes aortic dissection as a rare complication. We have experienced an autopsy case of aortic dissection due to GCA. The patient was an 87-year-old Japanese woman with Stanford type A aortic dissection who died 7 days after admission. Two years previously she had been diagnosed as having abdominal aortic aneurysm and undergone endovascular aneurysm repair (EVAR). Although she had no characteristic symptoms of GCA, autopsy revealed marked granulomatous inflammation in the dissected area and coronary arteries. Active arteritis was evident not only in the arteries of the upper extremity but also those in the lower extremity. Granulomatous inflammation was not evident in the aneurysm. The aortic dissection might have been an initial manifestation of GCA. We report the regions of GCA extension and its histology in detail.

Protocol for an interventional study to reduce postpartum weight retention in obese mothers using the internet of things and a mobile application: a randomized controlled trial (SpringMom).

BACKGROUND: Obese pregnant women are known to experience poorer pregnancy outcomes and are at higher risk of postnatal arteriosclerosis. Hence, weight control during and after pregnancy is important for reducing these risks. The objective of our planned randomized controlled trial is to evaluate whether the rate of change in body weight in obese women before pregnancy to 12 months postpartum would be lower with the use of an intervention consisting of Internet of Things (IoT) devices and mobile applications during pregnancy to 1 year postpartum compared to a non-intervention group. METHODS: Women will be recruited during outpatient maternity checkups at four perinatal care institutions in Japan. We will recruit women at less than 30 weeks of gestation with a pre-pregnancy body mass index ≥ 25 kg/m2. The women will be randomly assigned to an intervention or non-intervention group. The intervention will involve using data (weight, body composition, activity, sleep) measured with IoT devices (weight and body composition monitor, activity, and sleep tracker), meal records, and photographs acquired using a mobile application to automatically generate advice, alongside the use of a mobile application to provide articles and videos related to obesity and pregnancy. The primary outcome will be the ratio of change in body weight (%) from pre-pregnancy to 12 months postpartum compared to before pregnancy. DISCUSSION: This study will examine whether behavioral changes occurring during pregnancy, a period that provides a good opportunity to reexamine one's habits, lead to lifestyle improvements during the busy postpartum period. We aim to determine whether a lifestyle intervention that is initiated during pregnancy can suppress weight gain during pregnancy and encourage weight loss after delivery. TRIAL REGISTRATION: UMIN: UMIN (University hospital Medical Information Network) 000,041,460. Resisted on 18th August 2020. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047278.

The effect of roller head pump on platelet deterioration during the simulated extracorporeal circulation.

Roller pumping results in hemolysis and adverse effects on coagulation, but there are few reports on the influence of roller heads on platelets. Here, we evaluate the interaction between roller pumping and platelet function using a simulated extracorporeal circuit incorporating a vinyl chloride tube and roller head pump with 30 min recirculation. Platelet aggregation, platelet count, microparticle, P-selectin, Phosphatidylserine (PS) exposure and Ricinus Communis Agglutinin 1 (RCA-1) were measured before, 5, 10, 20, and 30 min after the recirculation using 100 ml of fresh human blood that had obtained from healthy volunteers (n = 9). Platelet aggregation and platelet count gradually decreased but microparticles significantly increased after the recirculation (P < 0.05). P-selectin, PS exposure and RCA-1 were measured using flow cytometry. There were no significant differences in the P-selectin and PS exposure expression during recirculation. RCA-1, a platelet apoptosis markers, significantly increased 30 min after recirculation (P < 0.05). We thus conclude that roller pumping induced platelet apoptosis and caused decreases in platelet count and aggregation after the recirculation.

Architecture matters: Tissue preservation strategies for tetralogy of Fallot repair.

BACKGROUND: Great variability exists in repair strategies for the tetralogy of Fallot. While transannular patching, as introduced by Kirklin, was a breakthrough for primary repair, pulmonary regurgitation and a need for reoperation have led to the development of methods that preserve the natural morphology of the right ventricular outflow tract. METHODS: State-of-the-art details of tetralogy of Fallot repair are explained from the standpoint of architectural preservation, especially with regard to sparing native tissue such as the annulus, valve, or infundibulum. Particular attention is given to the latest technical details of each approach, benefits and disadvantages, and any long-term data available. RESULTS: The choice of procedure is complex and unique to each case as transannular patching alone may carry long-term pulmonary risks. Modifications that spare the annulus, valves, or infundibulum may thus be essential as preservation of natural morphology has resulted in excellent mid-term results. CONCLUSIONS: The complexity of tetralogy of Fallot repair demands constant attention to clinical presentation and vigilance against long-term sequelae. Techniques will continue to improve over time as long-term data guides the refinement of these innovative surgical methods.

Surgical Management of Intraoperative Aortic Dissection in Type 3 Loeys-Dietz Syndrome with MYH11 Co-Mutation.

A 57-year-old female with Loeys-Dietz syndrome type 3 and MYH11 gene mutation underwent unexpected intraoperative ascending aortic dissection and subsequent rapid progression of the aortic arch dissecting aneurysm. Intra-surgical contingency plans with regard to aortic dissection and aneurysm should be considered for Loeys-Dietz syndrome, especially with comorbid mutations.

Adult Obstructive Cor Triatriatum with Severe Mitral Regurgitation: A Case Report.

Adult cor triatriatum sinister associated with severe mitral regurgitation is extremely rare. As these obstructive cor triatriatum feature hemodynamics that mimic mitral stenosis, a pressure load is theoretically generated only on the left atrial proximal chamber, and therefore the left ventricle is less likely to suffer volume loading. Here, we report a surgical case with such rare hemodynamics. A 22-year-old man with obstructive cor triatriatum and severe mitral regurgitation received an anomalous membrane excision and mitral annuloplasty. An abnormal membrane with an orifice 7 mm in size was completely resected while a grossly dilated mitral annulus was repaired via annuloplasty ring. Mitral regurgitation was controlled well, and the postoperative course was uneventful. Even with obstructive cor triatriatum, severe mitral annular dilatation and subsequent left ventricular dilatation may occur, causing the progressive heart failure encountered in this case.

Hybrid surgical and endovascular repair for anastomotic pseudoaneurysms after total arch replacement.

An 83-year-old woman who had undergone total arch replacement for a thoracic aortic aneurysm seven years prior experienced concurrent rupture of second and third branch anastomotic pseudoaneurysms. A stent graft was initially deployed across the pseudoaneurysm from the third branch to the left subclavian artery. Following the left axillary and left carotid arterial bypass, the origin of the second branch was embolized with metallic coils. As a result, both anastomotic pseudoaneurysms were undetectable by both completion angiogram and postoperative CT. By combining surgical and endovascular procedures, ruptured anastomotic pseudoaneurysms after total arch replacement can be repaired without a risky resternotomy.

[Aortic Valve Reoperation in Small Aortic Annulus].

Pediatric patients with narrow aortic valve annulus are often forced to undergo repeated aortic valve surgery, and it is not uncommon to plan a treatment strategy from the beginning with the assumption of reoperation or staged surgery. This article describes the anatomical structure of the aorto-mitral curtain and presents an example case of the Yamaguchi method, a relatively infrequently performed aortic valve procedure, in anticipation of aortic annular enlargement as a third reoperation in a 15-year-old boy with critical aortic valve stenosis. In the Nicks procedure, the incision beyond the posterior annulus is limited to the fibrous tissue of the aorto-mitral curtain;in the Manouguian procedure on the other hand, the incision is extended beyond this point to the anterior leaflet of the mitral valve. In the Yamaguchi procedure, the Konno incision at the anterior annulus near the right-left commissure is added to the standard Nicks incision for posterior annular enlargement, and thus the narrow annulus is enlarged in two places using two separate patches. However, the anterior incision cannot be very deep because the area immediately below the anterior annulus is nearly muscular tissue. Usually the annulus is enlarged with four posterior pledgets and additional two anterior pledgets.