Early postoperative pulmonary complications after minimally invasive esophagectomy in the prone position: incidence and perioperative risk factors from the perspective of anesthetic management.

OBJECTIVES: To investigate the incidence of and the risk factors for early postoperative pulmonary complications (PPC) after minimally invasive esophagectomy (MIE) in the prone position from the perspective of anesthetic management. METHODS: We conducted a historical cohort study of patients who underwent MIE in the prone position between September 2010 and August 2018. PPC was defined as pneumonia, atelectasis, acute respiratory distress syndrome (ARDS), respiratory failure, and pulmonary embolism (Clavien-Dindo Classification Grade II or higher) that occurred within 7 days after MIE. RESULTS: Out of 489 patients, there were 90 patients (18.4%) with PPC: 75 patients with pneumonia, 24 patients with atelectasis, 13 patients with respiratory failure, 6 patients with ARDS, and 2 patients with pulmonary embolism. Twenty-eight patients suffered from 2 or more components of PPC. PPC patients were older (66.6 vs. 63.6 year, P = 0.038) and had higher amount of crystalloid (4200 vs. 3550 mL, P < 0.0001), and longer duration of anesthesia (670 vs. 625 min, P = 0.0062) than non-PPC patients. PPC patients were more likely to have had chronic obstructive pulmonary disease (COPD) (26.7 vs. 7.8%, P < 0.001). Incidence of PPC was significantly higher in patients with one-lung ventilation than with two-lung ventilation (37.1 vs. 15.3%, P < 0.001). Multivariable logistic regression analysis showed that PPC was associated with age (per 10 years, odds ratio (OR) = 1.41), COPD (OR = 3.43), one-lung ventilation (OR = 1.94), and volume of crystalloid (per 500 mL, OR = 1.22). CONCLUSIONS: Two-lung rather than one-lung ventilation should be chosen and fluid overload should be avoided in patients undergoing MIE in the prone position.

Diagnostic performance and limitation of quantitative flow ratio for functional assessment of intermediate coronary stenosis.

BACKGROUND: This study aimed to simultaneously investigate diagnostic performance and limitation of quantitative flow reserve (QFR) for assessing functionally significant coronary stenosis, focusing on factors affecting diagnostic accuracy of QFR. METHODS: This study evaluated 1) QFR diagnostic accuracy compared with fractional flow reserve (FFR) in patients with stable coronary artery disease (Cohort-A, n = 95) and 2) QFR reproducibility for non-culprit lesions (NCLs) assessment between acute and staged (14±5 days later) procedures in patients with ST-segment elevation myocardial infarction (STEMI) (Cohort-B, n = 65). All coronary angiography image acquisition was performed before the introduction of QFR system into our institution. RESULTS: Cohort-A showed good correlation (r = 0.80, p<0.0001) between QFR and FFR; diagnostic accuracy of QFR for FFR ≤0.80 was 85.2% (sensitivity 80.4%, specificity 91.0%, positive predictive value 91.1%, negative predictive value 80.0%). There were 14 lesions showing discordance between QFR and FFR, which was primarily attributable to inadequate lesion visualization due to vessel overlap/tortuosity and/or insufficient intra-coronary contrast-media injection. In Cohort-B, there was also excellent correlation between acute and staged QFR; classification agreement of acute and staged QFR was 92.3%. Five lesions showed discordance between acute and staged QFR, 4 were due to limited image acquisition and/or high coronary flow velocity at acute phase of STEMI and 1 was borderline ischemia. CONCLUSIONS: QFR-derived physiological assessment of intermediate coronary stenosis is feasible, even in the acute setting of STEMI. Adjusting some technical factors may further improve the diagnostic performance of QFR.

Pharmacodynamic Assessment of Platelet Reactivity After a Loading Dose of Prasugrel or Clopidogrel in Patients With ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Few studies have compared the platelet reactivity of prasugrel and clopidogrel in the acute phase of ST-segment elevation myocardial infarction (STEMI).Methods and Results:Primary percutaneous coronary intervention (PCI) was performed in 78 patients with STEMI within 12 h of onset. Patients were randomly assigned to receive a Japanese standard loading dose of prasugrel 20 mg or clopidogrel 300 mg. Platelet reactivity was serially assessed using the VerifyNow-P2Y12 assay, the results of which were expressed as P2Y12-reaction-units (PRU). PRU values were significantly lower in the prasugrel group (n=38) than in the clopidogrel group (n=40) at 3 h, 24 h, and 14 days after loading (191±101 vs. 271±50, 147±80 vs. 261±57, and 171±67 vs. 221±70, respectively, P<0.05), although the PRU levels at baseline (231±57 vs. 237±58, P=0.65) and 1 h after loading (282±65 vs. 291±62, P=0.54) were similar. As compared with the baseline values, the PRU levels at 1, 3 and 24 h after clopidogrel loading were significantly higher (respectively, P<0.05), whereas only the PRU at 1 h after prasugrel was elevated (P<0.001). CONCLUSIONS: In Japanese patients with STEMI who undergo primary PCI, prasugrel provides stronger platelet inhibition than clopidogrel from 3 h after loading, whereas platelet reactivity remained elevated within 24 h after clopidogrel loading. (Circ J 2016; 80: 2520-2527).

Simultaneous fat and bone assessment in hospitalized heart failure patients using non-contrast-enhanced computed tomography.

BACKGROUND: Heart failure (HF) is associated with adverse metabolic influences and provokes fat loss as well as bone and muscle loss at the terminal stages. Pericardial fat is an ectopic fat depot that can potentially affect the myocardium, but the role of pericardial fat in HF is unclear. We sought to characterize pericardial fat in HF, particularly in association with bone tissue using cardiac computed tomography (CT). METHODS: In 61 consecutive hospitalized HF patients with left ventricular ejection fraction ≤50%, pericardial fat volume (PFV), CT density in the thoracic vertebrae, and ectopic calcification in the aortic valve were assessed simultaneously using electrocardiogram-gated non-contrast-enhanced CT. RESULTS: The mean PFV was 93.5±50.6cm(3), which might reflect the total body fat measured with dual energy X-ray absorptiometry (Pearson's r=0.48, p=0.01). The PFV index, defined as the PFV/body surface area, was significantly higher among older patients (>65 years; 63.5±30.6cm(3)/m(2) vs. 42.7±17.1cm(3)/m(2), p<0.01) and among patients with atrial fibrillation (AF; 70.9±36.4cm(3)/m(2) vs. 48.8±21.2cm(3)/m(2), p<0.01) and hypertension (60.7±29.3cm(3)/m(2) vs. 41.5±18.2cm(3)/m(2), p<0.01) compared to patients without these conditions. The PFV indices were comparable between the patients with and without ischemic etiology, diabetes, and renal dysfunction. Patients with increased PFV indices (above the median) exhibited lower CT density in the thoracic vertebrae (134±41 Hounsfield units vs. 161±57 Hounsfield units, p=0.04), and were more likely to have aortic valve calcification (48% vs. 18%, p=0.02) and N-telopeptide (bone resorption marker; 20.7±5.2nmolBCE/mmolCr vs. 25.5±5.9nmolBCE/mmolCr, p=0.03) levels than those without increased PFV indices. CONCLUSIONS: We simultaneously assessed the pericardial fat and bone tissue of HF patients with CT and successfully characterized AF, hypertension, and advanced age as factors that are associated with increased PFV. PFV was correlated with bone tissues and alterations in bone turnover.

Intravascular ultrasound assessment of the association between spatial orientation of ruptured coronary plaques and remodeling morphology of culprit plaques in ST-elevation acute myocardial infarction.

The aim of this study was to assess the association between the spatial location of plaque rupture and remodeling pattern of culprit lesions in acute anterior myocardial infarction (MI). Positive remodeling suggests a potential surrogate marker of plaque vulnerability, whereas plaque rupture causes thrombus formation followed by coronary occlusion and MI. Intravascular ultrasound (IVUS) can determine the precise spatial orientation of coronary plaque formation. We studied 52 consecutive patients with acute anterior MI caused by plaque rupture of the culprit lesion as assessed by preintervention IVUS. The plaques were divided into those with and without positive remodeling. We divided the plaques into three categories according to the spatial orientation of plaque rupture site: myocardial (inner curve), epicardial (outer curve), and lateral quadrants (2 intermediate quadrants). Among 52 plaque ruptures in 52 lesions, 27 ruptures were oriented toward the epicardial side (52%), 18 toward the myocardial side (35%), and 7 in the 2 lateral quadrants (13%). Among 35 plaques with positive remodeling, plaque rupture was observed in 21 (52%) on the epicardial side, 12 (34%) on the myocardial side, and 2 (6%) on the lateral side. However, among 17 plaques without positive remodeling, plaque rupture was observed in 6 (35%), 6 (35%), and 5 (30%), respectively (p = 0.047). Atherosclerotic plaques with positive remodeling showed more frequent plaque rupture on the epicardial side of the coronary vessel wall in anterior MI than those without positive remodeling.