Effects of Smoking on Ischemic Stroke, Intracranial Hemorrhage, and Coronary Artery Events in Japanese Patients With Non-Valvular Atrial Fibrillation.

The effects of smoking on the prognosis of non-valvular atrial fibrillation (NVAF) patients are unclear.The Shinken Database 2004-11 (n = 17,517) includes all new patients visiting the Cardiovascular Institute between June 2004 and March 2012. Among these cases, 2,102 NVAF patients were identified. The effects of smoking on ischemic stroke (IS), intracranial hemorrhage (ICH), and coronary artery events including percutaneous coronary intervention (PCI) and acute coronary syndrome (ACS) were analyzed. Smokers were younger and had lower risk profiles compared with non-smokers. A similar tendency was observed between current and former smokers. In contrast, patients with high tobacco consumption were older and had higher risk profiles, including uncontrolled hypertension, compared with those with low tobacco consumption. In 8,159 patient-years, IS, ICH, PCI, and ACS occurred at rates of 7.7, 2.7, 12.4, and 3.0 per 1000 patient-years. In multivariate Cox regression analysis, smoking was not significantly associated with any adverse event. However, different effects of smoking were observed when stratified by age. In patients ≥ 65 years old, current smokers were independently associated with PCI. Moreover, current smokers and smokers with a total tobacco amount ≥ 800 were marginally and independently associated with IS. In patients < 65 years, current smokers were independently associated with ICH.Age appears to be one of the contributors to differentiation of the effects of smoking on cardiovascular events in our NVAF patients. In elderly patients who still smoke, smoking was associated with the promotion of atherosclerosis or thromboembolism, whereas in young patients it was associated with bleeding.

A nationwide survey of aortic valve surgery in Japan: current status of valve preservation in cases with aortic regurgitation.

OBJECTIVE: Although aortic valve-sparing operations are performed throughout Japan, the indications, specific repair techniques, and outcomes have not been reported in full. Thus, we conducted the first nationwide survey of aortic valve-sparing surgery. METHODS: We mailed a questionnaire to 508 institutions across Japan to obtain information on elective aortic valve and aortic root surgeries performed in 2014. Included in the mailing was a secondary questionnaire that sought further information from institutions reporting aortic valve-sparing surgeries. RESULTS: Two hundred and fifty (49%) institutions responded and reported a total of 7859 aortic valve operations and 771 aortic root operations. Aortic valve operations performed strictly for aortic regurgitation totaled 2080, 156 (8%) of which were aortic valve repairs. Of the 699 aortic root surgeries performed for aortic regurgitation, 236 (34%) were valve-sparing root replacement surgeries. The valve-sparing root replacement surgeries comprised aortic valve reimplantation (n = 173, 73%) and aortic root remodeling (n = 63, 27%). Five of 57 (9%) institutions were responsible for 42% (99/233) of the total aortic valve-sparing surgeries performed. Detailed information that was obtained for 233 patients who underwent aortic valve repair or valve-sparing root replacement showed 30-day mortality and reoperation for regurgitation after aortic valve repair (n = 97), aortic root remodeling (n = 37), and aortic valve reimplantation (n = 99) to be 1, 0, and 1% and 3, 3, and 1%, respectively. CONCLUSION: To date, aortic valve-sparing operations have been performed for limited patients at limited institution in Japan, but the early outcomes have been excellent.

Comparison of early outcomes of surgical ablation procedures for atrial fibrillation concomitant to non-mitral cardiac surgery: a Japan Adult Cardiovascular Surgery Database study.

OBJECTIVE: Although the benefit of surgical ablation for atrial fibrillation (AF) performed concomitant to mitral valve surgery is established, whether that performed concomitant to non-mitral cardiac surgery is beneficial remains unclear. In non-mitral, non-left-atriotomy cardiac surgery, the optimal surgical approach for AF remains to be established. Therefore, using the Japan Adult Cardiovascular Surgery Database (JACVSD), we compared 2 surgical ablation procedures [the maze procedure and pulmonary vein isolation (PVI)] performed concomitant to non-mitral cardiac surgery. METHODS: Of 3402 JACVSD patients who had undergone elective non-mitral cardiac surgery by 2012, 1797 (53%) had undergone concomitant PVI, and 1339 (39%) had undergone the maze procedure. To compensate for patient heterogeneity, we conducted a propensity score-matched analysis of 1952 patients who had undergone PVI or the maze procedure (976 patients each). RESULTS: Operative procedures took significantly longer in the Maze Group. Although postoperative AF occurred in 34.3% of the PVI Group patients and in 31.9% of the Maze Group patients (p = 0.371), the incidence of first-time pacemaker implantation was significantly lower in the PVI Group (1.9 vs. 4.1%, respectively; p = 0.005). There was no significant difference in other morbidities or in operative mortality. Postoperative hospital and ICU stays tended to be longer in the Maze Group. CONCLUSIONS: Our data indicate that surgical ablation of AF concomitant to non-mitral cardiac surgery is beneficial. Furthermore, PVI and the maze procedure appear to be of equal benefit in this context, except that the maze procedure may more frequently result in the need for pacemaker implantation.

An Adult Case of Unicommissural Unicuspid Aortic Valve Diagnosed Based on the Intraoperative Findings.

We herein report an adult case of unicommissural unicuspid aortic valve (UAV). A 59-year-old man, who was noted to have a cardiac murmur at 31 years of age, was admitted to our hospital due to acute heart failure. Severe calcification in the aortic valve with severe low-flow/low-gradient aortic stenosis and moderate aortic regurgitation was observed and thought to be the cause of heart failure, however, the etiology of aortic valve dysfunction was not clear. Aortic valve replacement was subsequently performed, and unicommissural UAV was diagnosed according to the intraoperative findings. UAV is very rare congenital aortic valve disease which is rarely diagnosed preoperatively.

Midterm Outcome of Mitral Valve Repair with Artificial Chordae for Only Posterior Leaflet Disease-Comparison with the Resectional Technique in a Single Institute.

OBJECTIVE: We compared the midterm results of mitral valve repair with and without leaflet resection, and revealed the effectiveness of this technique, even for in the posterior leaflet alone. PATIENTS: From August 2002 to March 2014, a total of 306 mitral valve repairs were carried out at our hospital. Of these patients, 50 cases did not undergo leaflet resection (Artificial Chordae; Group A) and 56 cases underwent leaflet resection (Resectional; Group R). There were no significant differences in the preoperative profiles. RESULTS: The follow up rate was 98% and 100% respectively. The mean cardiopulmonary bypass time and aortic cross clamp time were not significantly different. The average ring size was significantly larger (p <0.01) in Group A. All cause mortality at 3 years and 8 years was both 97.8% in Group A and was both 98.1% in Group R. Freedom from moderate mitral regurgitation at 3 years was 97.1% and at 8 years was 91.7% in Group A and 97.4% and 94.6% in Group R respectively. There were no cases of mortality, re-operation for recurrent mitral regurgitation, hemolytic anemia and infectious endocarditis. CONCLUSION: We demonstrated good midterm results in mitral valve repair without leaflet resection. However, further follow-up was needed.

Association between smoking habits and the first-time appearance of atrial fibrillation in Japanese patients: Evidence from the Shinken Database.

BACKGROUND: We previously reported a cross-sectional analysis regarding the relationship between smoking and atrial fibrillation (AF) in a single hospital-based cohort with Japanese patients, but the effect of cessation of smoking and/or total tobacco consumption were unclear. METHODS AND RESULTS: We used data from the Shinken Database 2004-2011 (men/women, n=10,714/6803, respectively), which included all new patients attending the Cardiovascular Institute between June 2004 and March 2012. After excluding those previously diagnosed with AF (n=2296), 15,221 patients (men/women, n=9016/6205) were analyzed. During the follow-up period of 2.0±2.1 years (range 0.0-8.1), the incidence rates of new AF in smokers and non-smokers were 9.0 and 5.0 per 1000 patient-years, respectively. In adjusted models with Cox regression analysis, smokers were independently associated with new AF [hazard ratio (HR) 1.47, 95% confidence interval (CI) 1.09-2.00]. Also, current smokers (HR 1.81, 95% CI 1.17-2.79) and smokers with Brinkman index ≥800 (HR 1.69, 95% CI 1.05-2.70) were independently associated with new AF. However, in current smokers, the HRs were not different by Brinkman index (Brinkman index <800/≥800; HR 1.81/1.82, 95% CI 1.07-3.05/0.94-3.51, respectively). CONCLUSIONS: Smoking was independently associated with the first-appearance of AF in patients in sinus rhythm, especially when the patients continued their smoking habit. However, in patients who continued smoking, difference by total tobacco consumption was not observed, suggesting the significance of cessation of smoking for preventing AF. Our data are limited because of a single hospital-based nature and a relatively short observation period.

Preoperative estimated glomerular filtration rate as a significant predictor of long-term outcomes after coronary artery bypass grafting in Japanese patients.

PURPOSES: The aim of this retrospective study was to investigate the effect of chronic kidney disease (CKD) on outcomes after coronary artery bypass grafting (CABG), and to determine whether preoperative estimated glomerular filtration rate (eGFR) can be a predictor of long-term outcomes after CABG. METHODS: 486 Japanese patients who underwent isolated CABG between December 2000 and August 2010 were evaluated. Preoperative eGFR was estimated by the Japanese equation according to guidelines from the Japanese Society of Nephrology. We defined CKD as a preoperative eGFR of less than 60 ml/min/1.73 m(2). 203 patients had CKD (CK group) and 283 patients did not (N group). RESULTS: During a mean observation time of 53 months, the overall survival rate was significantly lower in the CK group than in the N group (p = 0.0044). Similarly, the CK group had significantly more unfavorable results with regard to freedom from cardiac death, major adverse cardiovascular and cerebrovascular events (MACCE), and hemodialysis. Using multivariate analyses, preoperative eGFR was an independent predictor of all-cause mortality (HR 0.983; p = 0.026), cardiac mortality (HR 0.963; p = 0.006), and incidence of MACCE (HR 0.983; p = 0.002). CONCLUSIONS: The CK group had significantly more unfavorable outcomes than the N group. Preoperative eGFR was an independent predictor of long-term outcomes after CABG in Japanese patients.

[The surgical treatment using inverted graft insertion technique for left ventricular aneurysm combined with aortic stenosis; report of a case].

An 83-year-old female with congestive heart failure[ New York Heart Association(NYHA) classification III ] due to left ventricular aneurysm, aortic stenosis( AS) with an aortic valve area of 0.66 cm2 and moderate tricuspid regurgitation, underwent endoventricular circular patch plasty using inverted graft insertion technique, aortic valve replacement (AVR) and tricuspid annuloplasty (TAP) successfully. It is highly probable that moderate aortic stenosis and localized apical transmural infarction had been gradually getting worse and they coincidentally caused both progressed AS and ventricular aneurismal change in our case.

Effects of smoking habit on the prevalence of atrial fibrillation in Japanese patients with special reference to sex differences.

BACKGROUND: Tobacco smoking is a well-known risk factor for cardiovascular disease, but controversial results have been reported regarding its relationship with atrial fibrillation (AF). Moreover, no study on the relationship between smoking and AF has yet been undertaken in a Japanese context. METHODS AND RESULTS: We used data from the Shinken Database 2004-2011 (men/women, n=10,714/6,803, respectively), which included all new patients attending the Cardiovascular Institute between June 2004 and March 2012. AF was diagnosed in 1,698 and 598 men and women, respectively. In men, smokers were more prevalent in the AF than in the non-AF group (54.5% vs. 44.7%), whereas in women the prevalence of smokers was similar between AF and non-AF groups (14.4% vs. 15.4%). This discrepancy between the sexes seems to derive from a characteristic distribution pattern of smoking habit in women. After adjustment for various cofactors, smoking was independently associated with AF (odds ratio 1.54; 95% confidence interval 1.35-1.75; P<0.001) without a significant interaction between sex categories (P=0.195). CONCLUSIONS: Smoking was independently associated with AF without a significant interaction between sex categories among Japanese patients visiting a cardiovascular hospital. Further studies using a prospective cohort design are required to confirm a causal link between smoking and AF in Japanese patients.

Pelvic abscess following internal iliac artery embolization prior to endovascular aneurysm repair.

We describe a previously unreported case of abscess formation around the right internal iliac artery (IIA) after coil embolization prior to endovascular aneurysm repair (EVAR). A 75-year-old man was admitted for elective repair of a right common iliac aneurysm. The right IIA coil embolization and EVAR procedures were uncomplicated and assessment by postoperative computed tomography (CT) was satisfactory. The patient was readmitted 2 weeks after EVAR with right buttock pain and pyrexia. CT indicated an isolated abscess around the coil-embolized IIA. The patient was successfully treated with CT-guided percutaneous drainage.

Efficacy of a heparin-coated closed circuit for intractable bleeding in adult cardiac surgery.

Hemostatic procedures and control of blood pressure concomitant with rapid transfusion of blood products aimed at recovery of coagulability are necessary for intractable bleeding during cardiac surgery. However, when the bleeding is massive and hemostasis is prolonged for several hours, operative maneuvers such as manual compression of the heart can affect hemodynamics, decrease cardiac output, and elevate atrial and venous pressure, with consequent hepatic, renal, and pulmonary dysfunction over time. Herein we present three cases of potentially fatal bleeding during open-heart surgery, in which we used a heparin-coated closed circuit for circulatory support after standard cardiopulmonary bypass. We achieved stable hemodynamics following surgical hemostatic maneuvers and avoided the postoperative multiple organ failure by using a cardiopulmonary support system.

Successful surgical repair for Emery-Dreifuss muscular dystrophy valvular disease with long-term follow-up.

Emery-Dreifuss muscular dystrophy (EDMD) is an X-linked muscular dystrophy in which cardiac involvement can be serious. The disease progresses rapidly and the prognosis is strongly associated with cardiac involvement. We present the case of a 49-year-old man who was admitted with shortness of breath. Echocardiography revealed a huge right atrium and severe tricuspid regurgitation caused by annular dilatation and destruction of leaflets and chordae by pacemaker leads. Tricuspid valve replacement, right atrial plication and implantation of epicardial pacemaker leads were performed. The patient is in a good condition seven years after surgery. Cardiac transplantation is the desired therapy for valvular disease in EDMD cardiomyopathy, but this case indicates that valve replacement is also acceptable if performed with the appropriate timing.

Carotid artery stenting via a femoral bypass graft: technical note.

BACKGROUND: We described a case of endoluminal stent placement for a cervical internal carotid artery stenosis in which access was obtained via the femoral bypass graft. CASE DESCRIPTION: A 70-year-old man with known disease of the carotid, peripheral, and coronary arteries as well as congestive heart failure presented for endoluminal revascularization of a severe right internal carotid artery stenosis. Transradial access was complicated by the left subclavian artery occlusion and hypercalcified aortic arch. Bilateral femoral artery was replaced with bypass graft because of atherosclerosis obliterans. An alternative approach was attempted via the exposed left femoral bypass graft. The left inguinal region was incised, and the left common femoral-popliteal bypass graft was exposed. After placement of a purse string suture at the puncture site, the guiding sheath was introduced into the graft and positioned into the right common carotid artery. Stenting was successfully performed, and the suture was tied after withdrawing the sheath. CONCLUSIONS: This novel approach should be considered for endovascular procedures for which access to the carotid artery is limited.

The efficacy of human atrial natriuretic peptide in patients with renal dysfunction undergoing cardiac surgery.

OBJECTIVES: The purpose of this study was to investigate the efficacy of carperitide (human atrial natriuretic peptide [h-ANP]) in perioperative management in patients with renal dysfunction, especially its kidney-protecting effects. PATIENTS AND METHODS: The subjects were 18 patients who underwent elective cardiac surgery using cardiopulmonary bypass (CPB) with a preoperative serum creatinine (Cr) level of 1.2 mg/dl or more. The subjects were prospectively assigned to 2 groups: an h-ANP-treated group (Group H, n = 10) and a non-h-ANP-treated group (Group N, n = 8). At the beginning of surgery, h-ANP administration was initiated and continued for 5 days or more. The central dose was 0.02 microg/kg/min. The primary end point included the serum Cr level and creatinine clearance (Ccr). RESULTS: In Group H, Cr level significantly decreased after surgery compared to the preoperative level. The Ccr values were significantly higher 2 and 3 days after surgery than the preoperative values. And the intraoperative urine volume significantly increased. In Group H, an increase in urinary N-acetyl-beta-D-glucosaminidase (NAG) level the day after surgery was significantly inhibited in comparison with Group N. CONCLUSION: The results of this study suggest that in patients with renal dysfunction before cardiac surgery, continuous low-dose h-ANP therapy maintains renal function, preventing its deterioration.

Comparison of the effects of aortic valve replacement using 19-mm Carpentier-Edwards Perimount bioprosthesis and 19-mm Medtronic Mosaic bioprosthesis.

OBJECTIVE: Short (< or =3 months)- and middle (> or =4 months)-term results of aortic valve replacement (AVR) using 19-mm Carpentier-Edwards Perimount (CEP) bioprosthetic valves and 19-mm Medtronic Mosaic (MM) bioprosthetic valves in patients with small aortic annulus were compared. PATIENTS AND METHODS: At our facility, AVR was performed using bioprostheses in 110 patients from April 1999 to March 2006. Of these patients, 40 were treated using 19-mm CEP (Group C), and 9 using 19-mm MM (Group M). Evaluation by inquiry, physical examination, and echocardiography was performed before, a short term after, and a middle term after surgery, and the effects of AVR were compared. RESULTS: The New York Heart Association (NYHA) functional class grade showed improvements in both groups. The aortic valve peak pressure gradient was 29.8 +/- 10.1 mmHg in Group C and 53.8 +/- 17.3 mmHg in Group M, being higher in Group M, a middle term after surgery. However, the left ventricular mass index (LVMI) showed improvements in both groups compared with the values before surgery, and the left ventricular ejection fraction (LVEF) was maintained. During the middle term after surgery, the frequency of cardiac events showed no significant difference between the two groups. CONCLUSIONS: In the patients treated with 19-mm MM, the aortic valve peak pressure gradient was higher than in those treated with 19-mm CEP, but acceptable improvements in the LVMI, maintenance of the LVEF, and avoidance of cardiac events were observed in both groups.

Perioperative and mid-term results of coronary bypass surgery in patients undergoing chronic dialysis.

PURPOSE: The goal of this study was to evaluate perioperative and mid-term results of coronary artery bypass grafting (CABG) in patients with end-stage renal disease (ESRD). METHODS: Thirty-five consecutive dialysis patients who required CABG over a 5-year period were investigated retrospectively. RESULTS: Mean patient age was 62.5+/-11.5 years. The mean number of diseased vessels was 2.3W0.8. Off-pump CABG (OPCAB) was performed in 12 patients. The mean number of anastomoses per patient was 2.5+/-1.1. The perioperative mortality was 5.7%, and the average duration of hospitalization was 25.3+/-13.4 days. Overall 5-year survival rates were 63.7%. The cardiac-related 5-year survival rate was 89.3%, and the cardiac event-free rate was 51.7%. Multivariate analysis failed to identify any significant prognosticators for perioperative or long-term outcomes. The morbidity rate was significantly lower in patients undergoing OPCAB than in patients undergoing conventional CABG (8.3 vs. 47.8%; p=0.03). Perioperative mortality in the OPCAB group was 0%, and the average duration of hospitalization was shorter in the OPCAB group than in the conventional CABG group (19.7 days vs. 28.5 days; p=0.1). CONCLUSION: In the context of coronary artery bypass surgery, OPCAB produced better outcomes than conventional CABG procedure in patients undergoing chronic dialysis. Further-more, OPCAB procedure seems to offer a greater benefit to dialysis patients than non-dialysis patients.

Off-pump coronary artery bypass grafting for acute myocardial infarction.

BACKGROUND: The aim of this study was to evaluate the surgical results of off-pump coronary artery bypass grafting (OPCAB) for patients with acute myocardial infarction (AMI) within 14 days of the infarction. METHODS AND RESULTS: From April 2000 to January 2005 among 841 patients who underwent OPCAB, 43 consecutive patients (5.1%) were examined. Mean age at operation was 69.5 years and mean time from the onset of AMI to surgery was 4.6 days. Seventeen patients (39.5%) had left main trunk disease. Three patients (7.0%) underwent OPCAB following unsuccessful percutaneous coronary intervention, and 1 patient (2.3%) underwent redo procedure 9 years after previous coronary artery bypass grafting (CABG). Six patients (14%) were admitted in cardiogenic shock. Intraaortic balloon pumping was inserted preoperatively in 20 patients (46.5%). The average maximum creatine kinase-myocardial band was 139+/-181 (U/L). The mean number of grafts was 3.2 and the rate of complete revascularization was 91%. Two of six patients with preoperative cardiogenic shock were converted to on-pump beating CABG due to ventricular arrythmia. The early graft patency rate was 98%. All patients survived except 2 with preoperative cardiogenic shock. CONCLUSIONS: OPCAB can be performed after AMI as a relatively low-risk procedure with an acceptable mortality rate, even within 14 days of the infarction.

[Arrested coronary artery bypass grafting with modified percutaneous cardiopulmonary support circuit (mini-pump system)].

Therapeutic strategy for ischemic heart disease has been changing in this decade. We attempted to improve the conventional extracorporeal circulation with the aim of less invasive coronary artery revascularization. Our extracorporeal circulation has been used since 2002, and called the 'mini-pump system' or 'MECC (minimized extracorporeal circulation) system'. The mini-pump system has a centrifugal pump, a membrane oxygenator, a soft reservoir and the characteristics of low prime volume completely closed circuit and low volume cardioplegia. We investigated the degree of invasiveness of the mini-pump system by examining the clinical outcomes (minimum hematocrit, the amount of transfusion and so on), thrombin-antithrombin III complex (TAT), complement factor (C3a) and interleukin (IL)-10 levels. The mini-pump system demonstrated better value than the conventional extracorporeal circulation (TAT; 19.5 : 66.1 ng/ml, C3a; 1,349 : 1,895 mg/dl, IL-10; 105 : 486 pg/ml, respectively) and proved to be less invasive. The incidence of postoperative atrial fibrillation using the mini-pump system was less than that of the conventional extracorporeal circulation. In this issue we presented the vista of the mini-pump system by showing how it decreased invasiveness.

Saccular aneurysm of the aortic cusp associated with discrete subaortic stenosis.

A 54-year-old male who experienced a syncopal episode underwent aortic valve replacement for aortic stenosis and regurgitation. The aortic valve was incompetent as a result of thickening of the left coronary cusp and noncoronary cusp. In addition a saccular aneurysm was indicated on the left coronary cusp. A shelf of tissue protruding at right angles from the ventricular septum was particularly prominent below the right coronary cusp, resulting in subvalvular stenosis. The cause of the saccular aneurysm was most likely caused by the long-term effects of the jet stream instigated by discrete subaortic stenosis.

Risk factors of posterior pericardial annuloplasty for isolated posterior leaflet prolapse.

BACKGROUND: Posterior autologous pericardial annuloplasty is an option in mitral valve repair. However, the durability of posterior pericardial annuloplasty remains controversial. METHODS: From June 1999 to July 2004, 49 patients (18 male and 31 female; mean age, 64 +/- 12 years) with isolated posterior leaflet prolapse received posterior autologous pericardial annuloplasty. Transthoracic echocardiographic examination before the operation, at the time of discharge, and then annually was performed and analyzed. RESULTS: There was no incidence of in-hospital or late death. Only 1 patient (2.1%) required reoperation. In terms of recurrent mitral regurgitation, 31 patients (64.6%) exhibited grade 0 mitral regurgitation, 7 patients (14.6%) exhibited grade 1, and 9 patients (18.8%) exhibited grade 2, whereas only 1 patient (2.0%) exhibited more than grade 3. In terms of predicting postoperative recurrence of significant mitral regurgitation (> or =grade 2), multivariate Cox analysis demonstrated that marked left atrial dilatation and high fractional shortening were independent risk factors. In 8 of 10 patients significant mitral regurgitation recurred after discharge. In terms of left atrial dimension, no significant reduction was observed in the postdischarge recurrent group, and there was a significant difference of left atrial dimension between the postdischarge recurrent group and the nonrecurrent group at the time of discharge. CONCLUSIONS: The merits of mitral valve repair using posterior autologous pericardial annuloplasty are attractive. However, its use should be limited in selected patients with isolated posterior leaflet disease, nonenlarged atria, and non-high fractional shortening to maintain the durability of the mitral valve repair.