Treatment Strategy of Endovascular versus Open Repair for Ruptured Abdominal Aortic Aneurysm Based on the Fitzgerald Classification.

BACKGROUND: The Fitzgerald classification expresses the extension of hematoma from the ruptured abdominal aortic aneurysm (rAAA) and is related to a patient's preoperative status. The objective of this study was to propose a new decision-making method for emergency surgeries, endovascular aortic repair (EVAR), or open repair (OR) for rAAA based on the Fitzgerald classification using preoperative computed tomography images. MATERIALS AND METHODS: A multicenter observational study was performed with a questionnaire survey of rAAA from August 2010 to July 2015 in Hokkaido, Japan, and sent to 20 institutions participating in the Hokkaido Society of Aortic Stent Graft. We included 205 patients who could be stratified by the Fitzgerald classification as the subjects of this study. We categorized these patients into Fitzgerald classes I and II (first category, n = 72) and classes III and IV (second category, n = 133). The short-term results of both EVAR and OR cases were examined in the 2 categories. RESULTS: In the first category, patients in the EVAR group were older than those in the OR group. Nonetheless, the in-hospital mortality rate was lower in the EVAR group than in the OR group (0% vs. 18%; P = 0.019). In the second category, there was no difference in preoperative factors between the groups. The EVAR group showed a higher incidence rate of postoperative abdominal compartment syndrome than the OR group (12% vs. 2%; P = 0.042). The in-hospital mortality rate was comparable between the groups (24% vs. 25%; P = 0.80). Although there were no deaths in the EVAR group without preoperative shock, in-hospital mortality in the EVAR group of the second category with shock was 41% (vs. 28% in the OR group; P = 0.27). Furthermore, mortality in the EVAR group with Fitzgerald class IV was 100% (vs. 29% in the OR group; P = 0.049). CONCLUSIONS: EVAR is recommended in Fitzgerald class I or II and also in Fitzgerald class III or IV without shock because the results of EVAR were better than those of OR. Because all patients who underwent EVAR died in Fitzgerald class IV, OR would be beneficial in this patient population.

Clinical results and medical costs of thoracic endovascular aortic repair in patients over 80 years of age.

Thoracic endovascular aortic repair (TEVAR) is expected to be minimally invasive, especially in older patients. However, clinical results of TEVAR in octogenarians including medical costs are limited. Between 2010 and 2016, a total of 57 patients over 80 years of age (mean age 84.1 ± 3.4 years) underwent TEVAR at our hospital. The proximal landing zone (PLZ) was zone 0 in 7 patients (12.3%), zone 1 in 10 patients (17.5%), zone 2 in 9 patients (15.8%), zone 3 in 13 patients (22.8%), and zone 4 in 18 patients (31.6%). The mean follow-up time was 23 ± 19 months (range 1-71 months). The follow-up rate was 96.5%. The hospital mortality rate was 1.8%. Stroke occurred in three patients (zone 0: 2, zone 3: 1, 5.3%). The mean hospital stay was 21.8 ± 21.4 days (range 5-98 days), and the rate of being discharged home was 84.2%. The 1-year and 3-year survival rates were 76.1% and 55.1% and the 1-year and 3-year re-intervention-free rates of the thoracic aorta were 97.6% and 94.5%, respectively. The mean total cost by the time of hospital discharge was ¥5,360,000 ± 2,360,000. The clinical results of TEVAR in patients over 80 years of age are acceptable with early postoperative recovery, low mortality and morbidity, and midterm durability.

Re-do mitral valve replacement for a bioprosthetic valve with central transvalvular leakage in a patient with ischemic cardiomyopathy: a case report.

Transvalvular leakage (TVL) of a prosthetic heart valve is not negligible regurgitant flow in patients with critically low contractile function. Although the opening function of prosthetic valves has been reported, its closing function is not well understood. A man in his 70 s had a history of mitral valve replacement (MVR) with a Magna Mitral® valve for ischemic mitral valve regurgitation. He presented with dyspnea 2 years postoperatively. Echocardiography showed moderate TVL. The pulmonary capillary wedge pressure and cardiac index were 37 mmHg and 1.65 L/min/m2, respectively. Because we considered his TVL relevant, we performed re-do MVR with a mechanical valve and papillary muscle approximation and suspension ("papillary muscle tugging approximation"). His cardiac function improved postoperatively; he was discharged with New York Heart Association class I. For MVR in patients with critically low contractile function, prosthetic valves, such as mechanical valves, with small TVL are recommended.

Mechanical properties of a new thermally deformable mitral valve annuloplasty ring and its effects on the mitral valve.

Ideally, an annuloplasty ring's shape should be changed intraoperatively if mitral valve repair is unsuccessful because of a short coaptation length or systolic anterior motion. Several post-implantation adjustable rings have been developed, but they are not freely deformable and are unsuitable for asymmetric repair of the valvular annulus. We developed a novel thermally deformable mitral annuloplasty ring to address these problems and assessed the ring's mechanical properties and its effect on the mitral valve anatomy. This ring was made of polycaprolactone. Tensile and bending tests were performed to evaluate the ring's mechanical properties. The ratio of the transverse and septal-lateral length was determined as 4:3. Using 10 pig hearts, we measured the post-deformation coaptation length and minimum distance from the coaptation to the ventricular septum, which is a factor of abnormal systolic anterior motion of the mitral valve. In the mechanical tests, the ring's yield point was greater than the deformation force of the annulus in humans. In pigs with deformation from "4:3" to "4:2", the coaptation length was significantly increased in each mitral valve part. In pigs with deformation from "4:3" to "4:4", the minimum distance from the coaptation to the ventricular septum was significantly increased. Asymmetrical ring deformation increased the coaptation length only at the deformed area. In conclusion, this new thermally deformable mitral annuloplasty ring could be "order-made" to effectively change the coaptation length in all parts of the mitral valve and the distance from the coaptation to septum post-deformation via intraoperative heating.

Anticoagulation management during cardiopulmonary bypass in patients with antiphospholipid syndrome.

Antiphospholipid syndrome (APS) is a complex autoimmune disease often related to systemic lupus erythematosus. Although adequate anticoagulation is important for APS patients during cardiopulmonary bypass, clotting tests can be potentially misleading due to antiphospholipid antibodies. We performed cardiac surgery safely in two APS patients under anticoagulation monitoring determined using preoperative heparin titration. We performed heparin titration for activated clotting time to determine the appropriate heparin concentration during cardiac surgery. We changed the targeted heparin concentration considering each patient's thrombotic risks: 3 U/ml of heparin for a normal-risk APS patient and 5 U/ml for a high-risk APS patient with a history of antiphospholipid-antibody-associated thrombocytopenia. A higher targeted heparin concentration might be necessary for patients with high thrombotic risks.

[Surgical Options for Refractory Heart Failure Patients with Non-ischemic Dilated Cardiomyopathy].

Surgical strategy for non-ischemic dilated cardiomyopathy (NIDCM) is currently controversial. Subjects were 20 patients who underwent left ventriculoplasty(LVP) from 2006 to 2013 and 6 patients who underwent papillary muscle tugging approximation (PMTA) after 2015. PMTA is a new trans-mitral approach combined with valve replacement without left ventriculotomy. Another group of patients( n=14)who were registered for heart transplantation( HTx) after 2013 was also analyzed for left ventricular assist device(LVAD) free survival. Mw( slope in the preload recruitable stroke work relationship) calculated by single beat technique using echocardiography was employed as a load-independent cardiac functional parameter. The baseline characteristics and Mw were not different between the LVP and PMTA groups. One-year survival was significantly lower in the LVP group(53%)than in the PMTA group(100%)[log-rank:p=0.024]. In the HTx group, early LVAD implantation was necessary in the patients who had low Mw(<20)at the time of registration. In conclusion, PMTA would be one option for NIDCM patients( non-HTx candidates) with severe mitral regurgitation. Early LVAD implantation might be predicted in HTx candidates with low Mw(<20).

Enlargement of aortic arch vessels after surgical repair of type A aortic dissection.

BACKGROUND: Information on the growth rate of the diameter of the residual dissected supra-aortic trunk after surgical repair of type A aortic dissection is limited. METHODS: We retrospectively reviewed 95 consecutive postsurgical patients with type A aortic dissection (acute, 91; chronic, 4) between 2005 and 2016 who were followed up with computed tomography. The diameter of the residual dissected supra-aortic trunk was measured by axial images and multiplanar reformatting, and the growth rate was calculated. RESULTS: The mean age was 67.2 ± 12.8 years (range, 34-89 years). Forty-one brachiocephalic arteries (43%), 14 left common carotid arteries (15%), and 7 left subclavian arteries (10%) exhibited residual dissection. The diameter of the residual dissected branch with a patent false lumen (FL) gradually increased over time, whereas that with a thrombosed FL decreased and reached a plateau. The growth rate of brachiocephalic, left common carotid, and left subclavian arteries with a patent FL was 1.3 ± 1.2, 0.8 ± 0.3, and 0.6 ± 0.4 mm/y, respectively. One patient required surgical intervention for dilation of the brachiocephalic artery 8 years postoperatively. Multivariate analysis showed that male sex was an independent risk factor for a patent FL in the brachiocephalic artery (P = .0431; odds ratio, 2.04). CONCLUSIONS: A residual dissected supra-aortic trunk with a thrombosed FL seems to be a benign condition. However, long-term follow-up is necessary for patients with a patent FL of residual dissected supra-aortic trunk, which might occasionally require surgical intervention.

Intraocular Pressure Changes in Non-Surgical Eyes of Patients Admitted for Glaucoma Surgery.

(1) Background: In glaucoma patients, it is observed that intraocular pressure (IOP) in non-surgical eyes decreases during hospitalization, but detailed data have not been reported. This study aimed to examine changes in IOP in the non-surgical eyes of patients admitted for glaucoma surgery. (2) Methods: This retrospective study included 487 patients (254 males, 233 females). Statistical analysis was performed separately for groups that were and were not under medication treatment. (3) Results: In non-surgical eyes, the difference in IOP between admission and discharge was -1.6 ± 4.8 mmHg (95% confidence interval (CI), -2.1 to -1.2; p < 0.0001) with a significant decrease in the medication group (n = 414), while it was -0.6 ± 4.8 mmHg with no significant change observed (95% confidence interval (CI), -1.7 to 0.57; p = 0.33) in the non-medication group (n = 73). Multiple regression analysis of the medication group showed that IOP at admission (p < 0.0001) and older age (p = 0.03) were associated with the reduction or the rate of reduction in IOP. (4) Conclusions: IOP in the non-surgical eyes of patients admitted for glaucoma surgery with medication decreased during hospitalization. The reduction was more pronounced in individuals with higher IOP at admission and in older patients. It is possible that improved medication adherence contributes to the lowering of IOP.

Exploring Cognitive Impairments Associated with Primary Open-Angle Glaucoma and Exfoliation Glaucoma.

This study explored the link between different types of glaucoma and cognitive function in a cohort of 620 Japanese patients. Participants were categorized into primary open-angle glaucoma (PG), exfoliation glaucoma (EG), and non-glaucomatous control groups. The findings revealed a significant decline in cognitive function as indicated by the Mini-Cog test in the EG group (mean ± SD: 4.0 ± 1, 95% CI: 3.9 to 4.2) compared to the PG group (4.4 ± 0.1, 4.3 to 4.5, p < 0.0001). Levels of fingertip measured advanced glycation end-products (AGEs) were significantly higher in the EG group (mean ± SD: 0.45 ± 0.006, 95% CI: 0.44 to 0.46) compared to the PG group (0.43 ± 0.004, 0.42 to 0.44, p = 0.0014). Although the multivariate analysis initially showed no direct association between glaucoma types and Mini-Cog scores, the EG group exhibited higher age and intraocular pressure (IOP) compared to the PG group. Further analysis revealed that high levels of AGEs were associated with cognitive decline and decreased mean visual fields in the EG group. Age was identified as a cofounding factor in these associations. An inverse correlation was observed between the accumulation of AGEs and skin carotenoid levels. Early detection of cognitive decline in glaucoma patients could enable timely intervention to preserve visual fields. Fingertip measurements of skin carotenoids and AGEs offer promising potential as non-invasive, straightforward diagnostic tools that could be widely adopted for monitoring ophthalmic and cognitive health in glaucoma patients.

Interrelation between myocardial oxidative metabolism and diastolic function in patients undergoing surgical ventricular reconstruction.

PURPOSE: Diastolic function is impaired in patients with end-stage heart failure. Favorable structural changes by surgical ventricular reconstruction (SVR) are thought to improve diastolic function, however, previous studies reported the contradictory results. We hypothesized that cardiac oxidative metabolism and diastolic dysfunction might improve in parallel to the reduction of left ventricular chamber size after SVR. METHODS: We studied 11 patients underwent SVR associated with mitral valve repair for end-stage heart failure due to dilated cardiomyopathy. Diastolic function was assessed by echocardiography and myocardial oxidative metabolism was measured by the monoexponential clearance (k-mono) of (11)C-acetate positron emission tomography at baseline and 1 month after SVR. RESULTS: All patients had preoperative severe diastolic dysfunction [E/A 4.11 ± 1.18, deceleration time (DT) 134 ± 26 ms]. The study patients were divided into 2 groups according to the changes in diastolic function after SVR; unchanged or worsened diastolic function in 6 patients (55 %, Non-responder) and improved diastolic function in 5 (45 %, Responder). K-mono and wall stress decreased only in responder. The changes in k-mono before and after SVR correlated with those in deceleration time (r = -0.63; p < 0.05) and wall stress (r = 0.75; p < 0.01). CONCLUSIONS: Improvement of diastolic dysfunction in patients with end-stage heart failure by SVR was in parallel to that in oxidative metabolism. It suggests that SVR reduced excessive metabolism during the diastolic phase, in part, via the improvement in diastolic function and the reduction in LV wall stress.

Preoperative regional left ventricular wall thickening determined by quantitative gated SPECT as a predictor of mid-term surgical results for ischemic and nonischemic cardiomyopathy.

BACKGROUND: This study aimed to elucidate whether regional left ventricular wall thickening (LVWT) determined by quantitative gated SPECT (QGS) is useful in predicting surgical outcomes for ischemic (ICM) and nonischemic cardiomyopathy (NICM). METHODS AND RESULTS: The study group comprised 53 patients with either ICM (n=30, left ventricular ejection fraction (LVEF)=24.7±7.1%) or NICM (n=23, LVEF=24.0±6.3%) scheduled for surgical repair underwent preoperative QGS to evaluate regional LV function. LVWT of 20 segments derived from QGS was normalized by being divided by the normal value of each LV level. Normalized values of the segments were summed to be representative of each area. For 16 of the 30 patients with ICM and 17 of the 23 patients with NICM, surgical ventricular restoration and papillary muscle approximation (PMA) were performed for surgical repair and, for the rest, PMA alone was done for both ICM and NICM patients. Adjunctive coronary artery bypass grafting for ICM patients was added when necessary. Mean follow-up periods were 2.5±1.8 years for ICM and 2.2±2.4 years for NICM. Posterior regional LVWT in NICM (normalized sum value <0.61 n=7, ROC: AUC=0.80) predicted cardiac events (chronic heart failure and cardiac-caused death). The one-year cardiac event-free rates were 22.2% and 85.1% and the 2 years rates were 11.1% and 48.6% for the lower posterior WT group and higher posterior WT group respectively (P=0.003). CONCLUSIONS: Posterior LVWT can be a predictor for postoperative cardiac events in patients with NICM.

[Optimal indication for surgical ventricular restoration for dilated cardiomyopathy].

In this study, we assessed mid-term results of surgical ventricular restoration (SVR) for dilated cardiomyopathy. The study subjects were 107 patients who underwent SVR for both ischemic (ischemic cardiomyopathy:ICM, n=57) and non-ischemic (dilated cardiomyopathy:DCM, n=50) dilated cardiomyopathy. In 49(86%)patients ICM was associated with New York heart Association(NYHA) class III or more. Preoperative left ventricular ejection fraction (LVEF) and left ventricular end-diastolic dimension(LVDd)were 22±6% and 67±9 mm, respectively. Hospital mortality was 14% and 5-year mortality was 40%. In contrast, 46( 92%) of the DCM patients presented with NYHA class III or more. Preoperative LVEF and LVDd were 20±6% and 74±9 mm, respectively. Hospital mortality was 28% and 5-year mortality was 63%. For NYHA class III or less, however, 5-year mortality rates were 23% and 39% in those with ICM and DCM, respectively. For those with NYHA functional class III or less, SVR was associated with a satisfactory survival rate and is recommended. For those with severe heart failure, however, ventricular assist devices or heart transplantation may have to be indicated.

Comparison of two spike areas in bileaflet mechanical valve closing sound.

We previously reported our development of a wavelet analysis system which demonstrates that in vivo bileaflet mechanical valve sound splits into two spikes at higher frequency levels and, based on this system, proposed criteria for detecting malfunctioning bileaflet valves (MBVs). However, the results of that study were only tentative due to the small number of patients with MBVs enrolled in the study. Here, we discuss the possibility of new criteria based on the scalographic properties of two spikes of bileaflet valve sound. The study cohort comprised 12 patients who each received a Carbomedics valve. Based on cinefluoroscopy findings, seven valves were classified into a "normal" group, and the other five were classified into a "malfunction" group. Five consecutive valve sounds for each valve were collected for the wavelet analysis in order to re-evaluate the previously proposed criteria and to measure both anterior spike area (Aa) and posterior spike area (Pa) for calculating the spike area ratio (Aa/Pa). The proposed criteria, namely, a single spike or coefficient of variation of <0.1120 detected only two of the five malfunctioning valves, as well as one normal valve to be malfunctioning. The mean Aa/Pa of all malfunctioning valves [2.45 ± 0.63; 95 % confidence interval (CI) ±1.01, 95 % confidence limits (CL) 1.44-3.46] was significantly higher than that of all normal valves (1.17 ± 0.27; 95 % CI ±0.25, 95 % CL 0.92-1.42). Based on this result, we determined the cutoff value of Aa/Pa to be 1.4. The combination of a single spike on the scalogram and an Aa/Pa of >1.4 detected more MBVs than previously proposed criteria. This combination may represent new criteria for detecting MBVs.

Postoperative atrial fibrillation: mechanism, prevention, and future perspective.

Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, despite improvements in anesthesia, surgical techniques, and medical therapies. Although beta-blockers have been proven to be effective, the incidence of POAF is around 20 % even with these agents. The mechanism of POAF is not fully elucidated and no optimal strategy has been established for POAF. There are two important elements of "structural" and "electrical" remodelling of the atrium in the mechanism of POAF. A patient's age and preoperative left atrial fibrosis can predict POAF associated with structural remodelling. Although inflammation and oxidative stress during cardiac surgery may be the underlying mechanisms for electrical remodelling causing POAF, there are no reliable clinical parameters for their detection. Nonetheless, postoperative P-wave dispersion and electromechanical delay, which reflects excitation-contraction coupling abnormalities, could be new parameters for POAF. In conclusion, despite the importance of prevention of POAF, there are only a few parameters for predicting POAF. It is therefore necessary to consider both disease-mediated structural remodeling before surgery and electrical remodeling caused by cardiac surgery.

Simple Chordal Replacement With a Newly Designed "Mitral Plate" in Mitral Valvuloplasty.

Mitral valvuloplasty using GORE-TEX as the artificial chordae is often associated with difficulties in determining the length of the artificial chordae, achieving the correct artificial chordae length, and preventing knot slippage, especially for beginners. We describe a simple technique involving a novel device called the "Mitral Plate," which enables surgeons to automatically determine the correct length of the artificial chordae and tie slippery knots without performing excessive saline tests.

Cytokine balance in hepatosplanchnic system during thoracoabdominal aortic aneurysm repair.

While prolonged visceral ischemia seems to be a potential source of elevated proinflammatory cytokines during thoracoabdominal aortic aneurysm (TAAA) repair, the underlying mechanisms are unclear. We have investigated the production of cytokines and fatty acid binding proteins (FABPs) in the hepatosplanchnic system during TAAA repair. Arterial and hepatic venous levels of tumor necrosis factor-alpha (TNF-α), interleukin (IL) -6, -8, and -10, and liver- and intestinal-type FABPs (L-FABP, I-FABP) were measured at four time points in ten patients undergoing TAAA repair. Visceral arteries were perfused through either a side-arm of distal aortic perfusion or an individual circuit using an independent pump, or both, without measuring perfusion pressure or blood flow. The postoperative courses of all patients were uneventful. During visceral perfusion, the levels of arterial IL-6, -8, and -10, and L-FABP elevated significantly (P = 0.0077, 0.0051, 0.0077, 0.0077, respectively), and these elevated levels persisted up to skin closure, with the exception of L-FABP (P = 0.0051 each). In contrast, there were only subtle increases in TNF-α and I-FABP levels. The production ratio through the hepatosplanchnic system of TNF-α, L-FABP, and I-FABP showed a pronounced peak during visceral perfusion, but only the peak of L-FABP was significant compared with baseline (P = 0.0077). All production ratios returned to baseline level at skin closure. The production ratio of IL-6 was negative throughout the operation and that of IL-8 and IL-10 remained at baseline during visceral perfusion. In conclusion, a portion of the TNF-α, L-FABP, and I-FABP might be produced temporarily in the hepatosplanchnic system during TAAA repair. Systemic elevation of IL-6, IL-8, and IL-10 might be modulated by inflammatory response to extracorporeal circulation or surgical stress. Thus, our simple visceral perfusion techniques may indeed be justified.

[Surgical ventricular restoration for ischemic cardiomyopathy].

In this study, we demonstrated the mid-term result of surgical ventricular restoration (SVR) for ischemic cardiomyopathy. Fifty-two patients (age 62 +/- 11 years) who underwent SVR between 2003 and 2010 were enrolled. Overlapping left ventriculoplasty, papillary muscle approximation, and coronary artery bypass grafting (CABG) were performed in 36 (69%), 39 (75%) and 46 (88%) patients, respectively. Preoperatively, 45 (87%) patients presented New York Heart Association (NYHA) class III/IV, whereas all patients presented NYHA I/III postoperatively (P < 0.01). left ventricular (LV) end-systolic volume index (LVESVI) and LV ejection fraction (LVEF) were improved postoperatively (LVESVI: 111 +/- 37 to 68 +/- 24, p < 0.01, LVEF : 30 +/- 9 to 37 +/- 11, p < 0.01). The degree of mitral regurgitation (MR) was 3+ or more in 27 (52%) patients, whereas 50 (96%) presented 1+ or less postoperatively (P < 0.01). The 1-, 3-, and 5-year survival rates were 90%. 83%, and 75%, respectively. Cox regression analysis demonstrated that preoperative MR 4+ was the significant predictor of postoperative death (P < 0.05, HR 5.2, 95% CI 1.2-22.9). Because of its satisfactory mid-term result, SVR would be validated as an effective procedure for ischemic cardiomyopathy.

A case of Carpentier-Edwards pericardial bioprosthesis in mitral position explanted 22 years after implantation.

A case of Carpentier-Edwards PERIMOUNT (CEP) mitral pericardial bioprosthesis explanted 22 years after the valve replacement is reported. This patient underwent the previous replacement at the age of 50. The extracted bioprosthesis showed three rigid leaflets, one of which had a tear causing severe mitral regurgitation. The X-ray demonstrated calcification of varied extent among these leaflets, ranging from none to severe. When leaflet calcification is suppressed, perhaps the lifespan of a CEP valve can be prolonged more than previously expected. When a literature search was conducted, this case was found to represent the longest reported interval from the implantation of a CEP valve in the mitral position to the explantation as a result of severe mitral regurgitation caused by structural valve deterioration (SVD).

Correlation between increased atrial expression of genes related to fatty acid metabolism and autophagy in patients with chronic atrial fibrillation.

Atrial metabolic disturbance contributes to the onset and development of atrial fibrillation (AF). Autophagy plays a role in maintaining the cellular energy balance. We examined whether atrial gene expressions related to fatty acid metabolism and autophagy are altered in chronic AF and whether they are related to each other. Right atrial tissue was obtained during heart surgery from 51 patients with sinus rhythm (SR, n = 38) or chronic AF (n = 13). Preoperative fasting serum free-fatty-acid levels were significantly higher in the AF patients. The atrial gene expression of fatty acid binding protein 3 (FABP3), which is involved in the cells' fatty acid uptake and intracellular fatty acid transport, was significantly increased in AF patients compared to SR patients; in the SR patients it was positively correlated with the right atrial diameter and intra-atrial electromechanical delay (EMD), parameters of structural and electrical atrial remodeling that were evaluated by an echocardiography. In contrast, the two groups' atrial contents of diacylglycerol (DAG), a toxic fatty acid metabolite, were comparable. Importantly, the atrial gene expression of microtubule-associated protein light chain 3 (LC3) was significantly increased in AF patients, and autophagy-related genes including LC3 were positively correlated with the atrial expression of FABP3. In conclusion, in chronic AF patients, the atrial expression of FABP3 was upregulated in association with autophagy-related genes without altered atrial DAG content. Our findings may support the hypothesis that dysregulated cardiac fatty acid metabolism contributes to the progression of AF and induction of autophagy has a cardioprotective effect against cardiac lipotoxicity in chronic AF.

Perioperative changes of the slope in the preload recruitable stroke work relationship by a single-beat technique after mitral valve surgery in functional mitral regurgitation with non-ischemic dilated cardiomyopathy.

OBJECTIVES: The slope in the preload recruitable stroke work relationship is a highly linear, load-insensitive contractile parameter. However, the perioperative change of the slope has not been reported before. We examined the perioperative slope from a steady-state single beat in patients with functional mitral regurgitation and assessed the correlation with brain natriuretic peptide (BNP) levels. METHODS: The study included 16 patients with non-ischemic dilated cardiomyopathy and refractory heart failure: 10 patients underwent mitral valve plasty and left ventricular plasty (MVP + LVP group) and 6 patients who underwent mitral valve replacement and papillary muscle tugging approximation (MVR + PMTA group). The left ventricular ejection fraction was assessed by the modified Simpson method; the slope was assessed by the single-beat technique using transthoracic echocardiography. BNP levels were measured by chemiluminescent immunoassay. RESULTS: The left ventricular ejection fraction and slope did not significantly change from pre- to early post-surgery in the MVP + LVP group. Both the left ventricular ejection fraction and slope significantly increased 6 months after surgery in the MVR + PMTA group. Postoperative BNP level was low in the MVR + PMTA group. While the postoperative left ventricular ejection fraction did not correlate with BNP levels, the postoperative slope significantly correlated with BNP level after surgery in the MVP + LVP group and in the total functional mitral regurgitation group. CONCLUSIONS: The change of slope was dependent on surgical procedures. In functional mitral regurgitation, the slope may be a more sensitive parameter in reflecting the left ventricular contractile function than the left ventricular ejection fraction.