Utility of new FDG-PET/CT guidelines for diagnosing cardiac sarcoidosis in patients with implanted cardiac pacemakers for atrioventricular block.

Diagnosing cardiac sarcoidosis (CS), especially in isolated cases, is challenging, particularly due to the limitations of endomyocardial biopsy, leading to potential undiagnosed cases in pacemaker-implanted patients. This study aims to provide real world findings to support new guideline for CS using 18F-fluoro-deoxyglucose positron-emission tomography computed tomography (FDG-PET/CT) which give a definite diagnosis of isolated CS (iCS) without histological findings. We examined consecutive patients with cardiac pacemakers for atrioventricular block (AV-b) attending our outpatient pacemaker clinic. The patients underwent periodical follow-up echocardiography and were divided into two groups according to echocardiographic findings: those with suspected CS and those without suspected CS. Patients suspected of having nonischemic cardiomyopathy underwent FDG-PET/CT for CS diagnosis. We investigated the utility of the new guideline for CS using FDG-PET/CT. Among the 272 patients enrolled, 97 patients were implanted with cardiac pacemakers for AV-b. Twenty-two patients were suspected of having CS during a median observation period of 5.4 years after pacemaker implantation. Of these, one did not consent, and nine of 21 cases (43%) were diagnosed with definite CS according to the new guidelines. Five of these nine patients were diagnosed with iCS using FDG-PET/CT. The number of patients diagnosed with definite CS using the new guidelines tended to be approximately 2.3 times that of the conventional criteria (p = 0.074). Three of the nine patients underwent steroid treatment. The composite outcome, comprising all-cause death, heart failure hospitalization, and a substantial reduction in left ventricular ejection fraction, were significantly lower in patients receiving steroid treatment compared to those without steroid treatment (p = 0.048). The utilization of FDG-PET/CT in accordance with the new guidelines facilitates the diagnosis of CS, including iCS, resulting in approximately 2.3 times as many diagnoses of CS compared to the conventional criteria. This guideline has the potential to support the early identification of iCS and may contribute to enhancing patient clinical outcomes.

Judkins right guiding catheter bailed out acute aortic insufficiency during balloon aortic valvuloplasty.

The introduction of transcatheter aortic valve implantation focuses attention on balloon aortic valvuloplasty (BAV) once again. BAV is effective for several clinical conditions, but fatal complications including acute severe aortic insufficiency may occur, although rare. We report a case of acute aortic insufficiency occurring during BAV, which was bailed out remarkably by the catheter method. When acute aortic insufficiency occurs during BAV, this simple and effective procedure should be attempted before conversion to emergency surgery.

Critical potential of early cardiac surgery for infective endocarditis with cardio-embolic strokes.

BACKGROUND: Early cardiac surgery may have a trade-off between stabilized hemodynamics with controlled infection and a risk of peri-operative death in patients with infective endocarditis (IE) complicated with cardio-embolic strokes. METHODS: We retrospectively studied clinical characteristics and outcomes in 68 consecutive patients with IE (mean age, 58±3years, 62% male) who admitted in our institute during June 2013 and August 2015. RESULTS: Cardio-embolic strokes were noted in 37% of patients (n=25) with IE and overall in-hospital mortality was 4 times higher in IE with cardio-embolic strokes than IE with an absence of strokes (n=43) (20% vs. 4.7%, p=0.045). Bacteremia of Staphylococcus aureus (p=0.021) and a complication of cardio-embolic strokes (p=0.031) were independently associated with in-hospital death in those with IE. However, in-hospital mortality was quite low in 19 with early cardiac surgery compared with 6 with conventional treatment in those with cardio-embolic strokes (11% vs. 50%, p=0.035). Multivariate logistic analysis demonstrated that lack of early cardiac surgery (p=0.014), a complication of cerebral hemorrhage (p=0.002), and a presence of refractory heart failure (p=0.047) were independently associated with in-hospital death in those with IE complicated with cardio-embolic strokes. CONCLUSION: Early cardiac surgery may provide clinical advantages overcoming peri-operative risks in those with IE complicated with cardio-embolic strokes.

[Permanent Neurological Deficit in Surgical Repair for Acute Type A Aortic Dissection].

BACKGROUND: This study elucidated incidence and risk factors of permanent neurological deficit( PND) after surgical repair of the acute type A aortic dissection. METHODS AND RESULTS: 669 patients who underwent emergent ascending/hemiarch replacement( AAR/HAR) and total arch replacement (TAR) were analyzed. AAR/HAR was performed in 441(65.9%) and TAR in 228 (34.1%). PND occurred in 58 patients(8.7%). Incidence of PND in AAR/HAR and TAR were 8.4% and 9.2% respectively(p=0.772). Logistic regression analysis showed preoperative conscious disturbance, preoperative paralysis, preoperative myocardial ischemia, and longer operation time associated postoperative PND. CONCLUSIONS: Rapid initiation of surgery after diagnosis and shorten operation time are advisable to improve outcomes. Preoperative neurological deficit and myocardial ischemia are risk factor of postoperative PND. Incidence of PND in AAR/HAR and TAR was equivalent.

Salvage transcatheter aortic valve implantation for severe acute aortic regurgitation complicating percutaneous transluminal aortic valvuloplasty.

With the advent of transcatheter aortic valve implantation (TAVI), percutaneous transluminal aortic valvuloplasty (PTAV) has experienced a recent renaissance. The roles of PTAV range widely from bridging to definitive therapy to palliation. In general, PTAV is performed without major trouble, but fatal complications including acute aortic regurgitation (AR) are occasionally encountered. We describe a case of severe acute AR complicating PTAV conducted for palliative purposes. Conversion to salvage TAVI bailed out this critical condition. This case demonstrates a new potential use of TAVI. .

A New Type of Mitral Valve Operation Using a Novel Stentless Mitral Valve made from Autologous Pericardium for Unrepairable Valve.

BACKGROUND AND AIM OF THE STUDY: The study aim was to create a new form of mitral valve surgery with a novel stentless mitral valve (SMV) made from autologous pericardium, for use in patients with an unrepairable valve. METHODS: A newly designed two-leaflet SMV ('NORMO') was developed, the excellent hydrodynamic function of which had been evaluated previously using a pulsatile simulator (data reported elsewhere). The operation involved constructing the NORMO valve by using autologous pericardium and a flexible ring, before instituting cardiopulmonary bypass and implanting the valve. The new-style operation was performed successfully in seven patients with complicated mitral valve disease who had requested valve repair rather than replacement. RESULTS: Postoperative echo-Doppler studies of the seven patients, performed at between six and 26 months (mean 18 months) after surgery, revealed mild mitral regurgitation (MR) in two cases and no or only trivial MR in the other five cases. CONCLUSION: Although its long-term durability is unknown, this new surgery might represent an alternative for mitral valve repair, especially in those patients with a complicated valve pathology where the feasibility of repair is low.

Is the threshold for postoperative prosthesis-patient mismatch the same for all prostheses?

PURPOSE: The effective orifice area index (EOAI) is used to define the prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR). However, few studies have so far evaluated whether the cutoff value for PPM varies across prostheses. This study assessed the hemodynamics in patients given a mechanical valve and then re-evaluated the validity of the commonly accepted threshold. METHODS: The subjects included 329 patients that underwent AVR with a St. Jude Medical Regent valve. The transvalvular pressure gradient and EOAI were determined echocardiographically, and the commonly accepted threshold was analyzed in relation to survival. RESULTS: The mechanical valves very often yielded a postoperative transvalvular pressure gradient >10 mmHg, and thus, clinically significant residual pressure, regardless of the EOAI. The slope of the curve describing the relationship between the transvalvular pressure gradient and EOAI was gentler than that reported for bioprosthetic valves, for which the pressure gradient rises sharply at EOAI <0.85 cm(2)/m(2). The commonly defined PPM did not affect the long-term survival or regression of the left ventricular mass index. CONCLUSIONS: The relationship between the transvalvular pressure gradient and the EOAI in patients given a mechanical prosthesis differed from the reference standard. These data suggest the need to reconsider the appropriate cutoff value for PPM in relation to different prostheses.

Short-term and long-term outcomes of postinfarction ventricular septal perforation.

PURPOSE: Ventricular septal perforation represents a serious complication after acute myocardial infarction. This study aimed to evaluate the short-term and longterm outcomes of postinfarction ventricular septal perforation (VSP). METHODS: We evaluated outcomes for VSP repair for 42 patients over 19 years. A retrospective analysis of clinical records, risk factors for hospital death, and long-term survival was performed. RESULTS: In-hospital mortality was 33.3%. The most common cause of hospital death was left-sided heart failure. A low ejection fraction and short time interval from acute myocardial infarction to the onset of VSP were significant risk factors. The actuarial survival rates of in-hospital survivors at 5 and 10 years were 81.7% and 43.5%, respectively. There were 17 cardiac events among the survivors during the follow-up period. The most influential factor affecting long-term outcomes was the number of diseased coronary arteries. CONCLUSION: The long-term survival outcome of VSP patients during the postoperative period was comparatively good, but the prognosis of VSP patients with multivessel disease was not satisfactory because of congestive heart failure or ventricular arrhythmia. We believe that postoperative medical treatment for preventing cardiac remodeling is important for improving long-term survival outcomes in such patients.

Surgical treatment for thoracic aneurysms: comparison of stent grafting and open surgery.

OBJECTIVES: Early and mid-term results of stent graft (SG) treatment for thoracic aortic aneurysms (thoracic endovascular aneurysm repair: TEVAR) were retrospectively compared with open surgical treatment. METHODS: The records of 213 patients in whom single thoracic aortic aneurysm repairs had been performed in our department from January 2006 through August 31, 2009 were reviewed. Acute aortic dissection was excluded. Each case was reviewed for indications for TEVAR from an anatomical standpoint. Among 62 cases in which TEVAR was indicated, 30 (SG group) were treated by TEVAR and 32, by open surgery (OP group). Early and mid-term results were analyzed retrospectively in both groups. RESULTS: There were no operative deaths in either group. The SG group demonstrated significantly less operative bleeding, a shorter operative time, and shorter postoperative hospital stay compared with the OP group. There were 3 deaths in the SG group and 4 in the OP group, which occurred within an average of 656.4 days during the follow up period. The 3 year actuarial survival rate was 88.7% in the SG group and 87.1% in the OP group, and there were no significant differences between the groups. CONCLUSION: Although early and mid-term results of TEVAR and open surgery were similar, TEVAR is generally less invasive and may be preferable for high-risk patients, compared with open surgical repair. (English Translation of Jpn J Vasc Surg 2010; 19: 51-56.).

Clinical outcomes and hemodynamics of the 19-mm Perimount Magna bioprosthesis in an aortic position: comparison with the 19-mm Medtronic Mosaic Ultra Valve.

BACKGROUND: When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch (PPM) is of concern because it can affect postoperative clinical outcomes. Although larger bioprosthetic valves have been well studied, the hemodynamics of 19-mm bioprostheses have been reported in only a small number of patients. The effectiveness as well as the impact of PPM on outcomes are thus still unclear. METHODS AND RESULTS: Postoperative clinical and hemodynamic variables were compared in 67 patients with a 19-mm Carpentier Edwards Perimount Magna bioprosthesis and in 10 patients with a 19-mm Medtronic Mosaic Ultra valve. Mean follow-up time was 13 months. There was no in-hospital mortality. Echocardiography 6.5±4.0 months after surgery showed significant decreases in the mean left ventricular (LV)-aortic pressure gradient, and decreases in the mean LV mass index. Reduction in LV mass index did not differ between the valve groups, despite a higher pressure gradient in the Mosaic group. Although PPM was detected in 21 patients in the Magna group, it did not affect regression of the LV mass index during the follow-up period. CONCLUSIONS: Use of the 19-mm Magna bioprosthesis appears to provide satisfactory clinical results. LV-aortic pressure gradient was lower in the Magna group. The present data suggest that PPM is not related to reduction in the LV mass index.

Clinical experience with a new vascular graft free from biodegradable material.

Triplex (Terumo Co., Tokyo, Japan), a newly developed large diameter vascular graft sealed with a non-biodegradable material, is expected to reduce inflammatory reaction. We confirmed its safe implantation and assessed inflammatory reaction after thoracic aortic surgery. Between January 2009 and February 2010, 101 consecutive patients underwent thoracic aortic replacement. Triplex grafts were implanted in 40 patients, and bovine-collagen coated grafts (Hemashield, Boston Scientific, Boston, MA, USA) were implanted in 61 patients. During the postoperative course, body temperature and laboratory findings including inflammatory markers were examined. The mean operation time and amount of bleeding during operation were equivalent in the two groups. The mean body temperature and C-reactive protein in patients implanted with Triplex were significantly lower than those in patients implanted with Hemashield grafts. The mean white blood cell count tended to be at lower levels in patients implanted with Triplex grafts. No patients in both groups suffered postoperative complications associated with the prosthetic grafts. Triplex was confirmed to be safely applied for thoracic aortic surgery as well as the conventional vascular grafts and to reduce postoperative inflammatory reaction.

Successful usage of extracorporeal membrane oxygenation as a bridge therapy for acute pulmonary embolism between hospitals.

A 50-year-old man presented to a nearby hospital with loss of consciousness. Investigation revealed thrombus formation at the tricuspid valve. Due to suspected pulmonary embolism, the patient underwent contrast-enhanced computed tomography during which he went into a shock with sudden drop in functional oxygen saturation (SpO(2)). Extracorporeal membrane oxygenation (ECMO) was introduced for cardiovascular and respiratory support, and he was transferred to our hospital for further treatment. The patient was treated by surgical thromboembolectomy and was dismissed from the hospital without major complications. We have experienced a case where ECMO was successfully used for cardiovascular and respiratory support, serving as a bridge therapy between hospitals.

The efficacy of intravenous milrinone in left ventricular restoration.

PURPOSE: The aim of this study was to clarify the efficacy of intravenous milrinone in postoperative care for patients following left ventricular (LV) restoration (LVR). METHODS: Fourteen patients who had ischemic cardiomyopathy with an LV ejection fraction (LVEF) of less than 0.30 and an LV end-systolic volume index of more than 100 ml/m2 underwent coronary artery bypass grafting and concomitant LVR. The patients received perioperative management with continuous infusions of 0.5 microg/kg/min milrinone that were started at the induction of a cardiopulmonary bypass (CPB). The perioperative course and outcome of these patients were retrospectively compared with those of matched LVR patients (n = 14) without milrinone administration during perioperative management. RESULTS: The preoperative LV end-diastolic pressure (26.3 mmHg vs. 15.4 mmHg) and early diastolic filling velocity/atrial filling velocity ratio (4.1 vs. 2.1) in the milrinone patients were significantly worse than those in the control. Even though the preoperative LV function in each patient demonstrated to be extremely poor, the perioperative hemodynamic variables were stable. The administered doses of dobutamine (4.01 vs. 5.81 microg/kg/min) and epinephrine (0.017 vs. 0.038 microg/kg/min) at the end of CPB were significantly lower in the milrinone patients compared to control. CONCLUSION: In those patients who underwent LVR because of ischemic cardiomyopathy, the administration of milrinone achieved safe perioperative management for stable hemodynamics and reduced the postoperative doses of dobutamine and epinephrine.

The 17-mm St. Jude Medical Regent valve is a valid option for patients with a small aortic annulus.

BACKGROUND: When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern. Such prosthesis-patient mismatch may affect postoperative clinical status and survival. We investigated the outcomes of isolated aortic valve replacement performed with a 17-mm mechanical prosthesis in patients with aortic stenosis. METHODS: Twenty-three patients with aortic stenosis (mean age, 74.6 +/- 6.3 years) underwent isolated aortic valve replacement with a 17-mm St. Jude Medical Regent prosthesis. Mean body surface area was 1.41 +/- 0.13 m(2). Preoperative echocardiography yielded a mean aortic valve area of 0.36 +/- 0.10 cm(2)/m(2), a mean left ventricular-aortic pressure gradient of 68.4 +/- 25.3 mm Hg, and a mean left ventricular mass index of 200 +/- 69 g/m(2). RESULTS: There was no operative mortality, and there were no valve-related events. Echocardiography at 14.0 +/- 10.0 months after aortic valve replacement showed a significant increase in the mean effective orifice area index (0.95 +/- 0.24 cm(2)/m(2)), decrease in the mean left ventricular-aortic pressure gradient (17.4 +/- 8.2 mm Hg), and decrease in the mean left ventricular mass index (124 +/- 37 cm(2)/m(2)). Prosthesis-patient mismatch (effective orifice area index < 0.85 cm(2)/m(2)) was present in 8 patients at discharge. In these patients as well as in those without prosthesis-patient mismatch, the left ventricular mass index decreased remarkably during follow-up. CONCLUSIONS: Aortic valve replacement with a 17-mm Regent prosthesis appears to provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus. Remarkable left ventricular mass regression during follow-up was achieved irrespective of the effective orifice area index at discharge.

Coronary artery bypass grafting using an abdominal artery as an inflow.

BACKGROUND: In multiple bypass surgery, when the ascending aorta cannot be used as an inflow, it is sometimes necessary to use an abdominal artery. This technique is useful when a re-median sternotomy might damage a patent graft in patients undergoing reoperations or when the gastroepiploic artery is unsuitable for use as a graft. METHODS: The subjects were 17 patients in whom an abdominal artery was used as an inflow. In these 17 patients, 9 underwent surgery for the first operation, while 8 underwent surgery for the reoperation. As an inflow, the gastroduodenal artery was used in 8 patients, the common hepatic artery in 4 patients, the left gastric artery in 3 patients, the right gastric artery in 1 patient, and the middle colic artery in 1 patient. The target coronary artery was the right posterior descending artery in 13 patients, the atrioventricular artery in 2 patients, and the circumflex artery in 4 patients. Sequential bypass was performed on 2 patients. RESULTS: None of the patients died during surgery. Symptoms disappeared postoperatively in all patients; postoperative angiography showed that all grafts were patent. CONCLUSIONS: The present technique is useful when the ascending aorta cannot be used as an inflow or when a bypass to a region with a large perfusion area is needed in multiple bypass surgery.