Negative pressure wound therapy for prolonged surgical wound healing after brachiobasilic arteriovenous fistula creation in a patient with end-stage liver failure.

A 54-year-old male patient diagnosed with hepatorenal syndrome caused by decompensated alcoholic cirrhosis was referred for arteriovenous fistula (AVF) creation after initiation of hemodialysis. A brachiobasilic arteriovenous fistula (BBAVF) was created because neither forearm had suitable vasculature. Large-volume serous effusion from the incision persisted postoperatively, and we started negative pressure wound therapy (NPWT) for wound protection. The effusion volume decreased gradually; however, up to 80 ml of discharge continued daily. Re-operation was performed 35 days after the initial operation, followed by continued NPWT. The wound was almost healed 85 days after the primary surgery. We present a case of severe surgical wound complication after AVF creation in a patient with hemostatic and coagulation disorders and malnutrition caused by end-stage hepatic failure. We confirmed the usefulness of NPWT for excessive surgical wound effusion and the adequacy of BBAVF for vascular access.

Evaluation of systolic and diastolic properties of hypertensive heart failure using speckle-tracking echocardiography with high volume rates.

Left ventricular (LV) properties in hypertension (HTN) could be deteriorated by pressure overload, especially in endocardium, resulting in hypertensive heart failure (HHF). We sought to noninvasively examine LV systolic and diastolic functions at three myocardial layers in HTN and elucidate features of HHF by speckle-tracking echocardiography (STE) with high volume rates. We examined normotensive controls (n = 54), HTN patients without LV hypertrophy (LVH) (n = 50), and HTN patients with LVH (n = 40) and HHF patients (n = 45). The HHF group was divided into two subgroups based on their LVEF (20 heart failure with preserved ejection fraction: HFpEF and 25 heart failure with reduced ejection fraction: HFrEF). LV layer systolic function was assessed by strain rate during systole. Pulmonary capillary wedge pressure (PCWP) was estimated (ePCWP) using kinetics-tracking index (KT index) that we previously reported. HTN patients with LVH had a significant deterioration of systolic and diastolic properties compared with normotensive controls in the absence of a significant reduction in LVEF. Patients with HHF had further deterioration of systolic and diastolic properties compared with HTN patients with LVH. LV strain at entire myocardium and ePCWP in HFrEF was deteriorated compared with those in HFpEF. Deterioration of LV layer SR was more typical during systole, isovolumic relaxation, and early diastole compared with control. LV dilation was independently associated with LVEF (r = -0.48, p < 0.001) and ePCWP (r = 0.47, p < 0.001), and LVH (LV mass index) was independently associated with E/e' (r = 0.37, p = 0.025), LVEF (r = -0.44, p < 0.001), and ePCWP (r = 0.67, p < 0.001). LV layer analysis by STE could detect subtle impairments in systolic function before the deterioration of LVEF in patients with HTN. The ePCWP that was estimated using KT index was the independent factor associated with HHF. The ePCWP may be useful to noninvasively detect the early stage of HHF.

Left ventricular layer function in hypertension assessed by myocardial strain rate using novel one-beat real-time three-dimensional speckle tracking echocardiography with high volume rates.

We recently developed novel software to measure phasic strain rate (SR) using automated one-beat real-time three-dimensional speckle tracking echocardiography (3D-STE) with high volume rates. We tested the hypothesis that left ventricular (LV) systolic function and relaxation analyzed by SR with the novel 3D-STE in hypertension (HTN) with hypertrophy may be impaired in the endocardium before there is LV systolic dysfunction. We measured LV longitudinal, radial and circumferential SR in patients with HTN (n=80, 69±7 years) and age-matched normotensive controls (n= 60, 69±10 years) using 3D-STE. HTN patients were divided into four groups according to LV geometry: normal, concentric remodeling, concentric hypertrophy and eccentric hypertrophy. We measured SR during systole as an index of systolic function, SR during isovolumic relaxation (IVR) as an index of relaxation and E/e' as an index of filling pressure. Endocardial SR during systole in HTN with concentric and eccentric hypertrophy decreased compared with that in controls despite no reduction in ejection fraction or epicardial SR. Endocardial radial SR during IVR decreased even in normal geometry, and it was further reduced in concentric remodeling and hypertrophy despite no reduction in epicardial SR. LV phasic SR assessed by 3D-STE with high volume rates is a useful index to detect early decreases in LV systolic function and to predict subclinical LV layer dysfunction in patients with HTN.

Anti-inflammatory and morphologic effects of pitavastatin on carotid arteries and thoracic aorta evaluated by integrated backscatter trans-esophageal ultrasound and PET/CT: a prospective randomized comparative study with pravastatin (EPICENTRE study).

BACKGROUND: We sought to evaluate the effects of a strong lipophilic statin (pitavastatin) on plaque components and morphology assessed by transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE), as well as plaque inflammation assessed by 18F-fluorodeoxyglucose (FDG) PET/CT in the thoracic aorta and the carotid artery. Furthermore, we compared the effects of pitavastatin with those of mild hydrophilic statin (pravastatin). METHODS: We examined atherosclerotic plaques in the thoracic aorta by TEE and those in the carotid artery by integrated backscatter (IBS)-TTE and PET/CT. We identified the target plaque, where there was macrophage infiltration and inflammation, by strong FDG uptake in the thoracic aorta and carotid arteries and measured maximum standard uptake values (max SUV) by PET/CT. We measured the intima-media thickness (IMT) and the corrected IBS (cIBS) values in the intima-media complex by TEE and TTE at the same site of FDG accumulation by PET/CT. RESULTS: Patients were randomly divided into two treatment groups: a pitavastatin group (PI group: n =10, 68.4 ± 5.1 years) and a pravastatin group (PR group: n =10, 63.9 ± 11.2 years). The same examinations were performed after six months at the same site in each patient. We used calculated target-to-background ratio (TBR) to measure max SUV of plaques and evaluated percent change of TBR. There was no significant difference in low density lipoprotein-cholesterol, TBR, IMT and cIBS values in plaques at baseline between the PI and PR groups. After treatment, there was greater improvement in TBR, cIBS values and IMT in the PI group than the PR group. CONCLUSIONS: The pravastatin treatment was less effective on plaque inflammation than pitavastatin treatment. This trend was the same in the carotid arteries and the thoracic aorta. Pitavastatin not only improved the atherosis as measured by IMT and cIBS values but also attenuated inflammation of plaques as measured by max SUV at the same site. The present study indicated that pitavastatin has stronger effects on the regression and stabilization of plaques in the thoracic aorta and carotid arteries compared with pravastatin.

Comparison between left atrial features in well-controlled hypertensive patients and normal subjects assessed by three-dimensional speckle tracking echocardiography.

BACKGROUND: Three-dimensional speckle tracking echocardiography (3D-STE) has a major advantage in the improvement of accuracy in the evaluation of cardiac chamber volume without any geometrical assumption. Thus, the aim of this study was to use 3D-STE to elucidate the features of left atrial (LA) volume and function that are altered by hypertension (HTN) by comparing well-controlled HTN patients with normal subjects. METHODS: Conventional echocardiographic parameters and LA phasic volume and function were measured from apical view by 3D-STE in 40 patients with well-controlled HTN [systolic blood pressure (BP) <140 and diastolic BP <90mmHg for more than one year] and 40 normotensive subjects. RESULTS: The passive LA emptying function (EF) in the patients with well-controlled HTN significantly decreased (16±7% vs. 22±8%, p=0.0013) and the active LAEF in patients with well-controlled HTN significantly increased (35±10% vs. 30±9%, p=0.029) compared with the values in normotensive subjects. Multivariate logistic regression analysis revealed that E/e' was an independent determinant of well-controlled HTN. The maximum LA volume index was correlated with elevated E/e' (r=0.30, p=0.0064), whereas the maximum LA volume index was not correlated with LV mass index or systolic BP. This change was independent of age. CONCLUSIONS: These results suggest that LV diastolic dysfunction occurs before structural changes of left atrium and left ventricle even in patients with well-controlled HTN.