Establishing clinical remission criteria for giant cell arteritis: Results of a Delphi exercise carried out by an expert panel of the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis.

OBJECTIVE: To develop a proposal for giant cell arteritis remission criteria in order to implement a treat-to-target algorithm. METHODS: A task force consisting of 10 rheumatologists, 3 cardiologists, 1 nephrologist, and 1 cardiac surgeon was established in the Large-vessel Vasculitis Group of the Japanese Research Committee of the Ministry of Health, Labour and Welfare for Intractable Vasculitis to conduct a Delphi survey of remission criteria for giant cell arteritis. The survey was circulated among the members over four reiterations with four face-to-face meetings. Items with a mean score of ≥4 were extracted as items for defining remission criteria. RESULTS: An initial literature review yielded a total of 117 candidate items for disease activity domains and treatment/comorbidity domains of remission criteria, of which 35 were extracted as disease activity domains (systematic symptoms, signs and symptoms of cranial and large-vessel area, inflammatory markers, and imaging findings). For the treatment/comorbidity domain, ≤5 mg/day of prednisolone 1 year after starting glucocorticoids was extracted. The definition of achievement of remission was the disappearance of active disease in the disease activity domain, normalization of inflammatory markers, and ≤5 mg/day of prednisolone. CONCLUSION: We developed proposals for remission criteria to guide the implementation of a treat-to-target algorithm for giant cell arteritis.

Endovascular Stent Graft Placement and Coil Embolization for Splenic Artery Aneurysm with an Anatomical Variant.

A 62-year-old woman with abdominal pain was diagnosed with a splenic artery aneurysm (SAA) and an anatomical variant in the splenic artery (SA) arising from the superior mesenteric artery (SMA) as its first branch. To treat the SAA, the draining artery and a small branch of the SAA were embolized, and then small-diameter stent grafts were deployed from SMA orifice, covering the aberrant origin of the SA and preserving the second branch of SMA. Intraoperative angiography confirmed successful exclusion of the SAA without endoleak or arterial dissection. The stent graft was patent and the aneurysm had shrunk 3.5 years after the operation.

Diamond-like carbon coating to inner surface of polyurethane tube reduces Staphylococcus aureus bacterial adhesion and biofilm formation.

Staphylococcus aureus is one of the main causative bacteria for polyurethane catheter and artificial graft infection. Recently, we developed a unique technique for coating diamond-like carbon (DLC) inside the luminal resin structure of polyurethane tubes. This study aimed to elucidate the infection-preventing effects of diamond-like carbon (DLC) coating on a polyurethane surface against S. aureus. We applied DLC to polyurethane tubes and rolled polyurethane sheets with our newly developed DLC coating technique for resin tubes. The DLC-coated and uncoated polyurethane surfaces were tested in smoothness, hydrophilicity, zeta-potential, and anti-bacterial properties against S. aureus (biofilm formation and bacterial attachment) by contact with bacterial fluids under static and flow conditions. The DLC-coated polyurethane surface was significantly smoother, more hydrophilic, and had a more negative zeta-potential than did the uncoated polyurethane surface. Upon exposure to bacterial fluid under both static and flow conditions, DLC-coated polyurethane exhibited significantly less biofilm formation than uncoated polyurethane, based on absorbance measurements. In addition, the adherence of S. aureus was significantly lower for DLC-coated polyurethane than for uncoated polyurethane under both conditions, based on scanning electron microscopy. These results show that applying DLC coating to the luminal resin of polyurethane tubes may impart antimicrobial effects against S. aureus to implantable medical polyurethane devices, such as vascular grafts and central venous catheters.

Prognostic impact of postoperative infection in patients with pancreatic cancer: A multicenter cohort study.

BACKGROUND: Postoperative infection after pancreatectomy in patients with pancreatic cancer often leads to poor prognosis. The aim of this study was to determine the prognostic effect of postoperative infection in patients with pancreatic cancer. METHODS: A multicenter cohort study was performed using a common database of patients with pancreatic cancer who underwent curative pancreatic resections between April 2013 and March 2015 at 15 high-volume centers in Japan. The rate of postoperative infection was determined, and patient demographic characteristics, clinicopathologic factors, and prognostic factors for overall survival were analyzed. RESULTS: Of the 462 eligible patients who underwent curative pancreatectomy, postoperative infection occurred in 141 patients (31%), including 114 surgical site infections (25%), 50 remote infections (11%), and 23 combined infections (5%). Risk factors for postoperative infection included high body mass index, nondiabetes, and longer operation time. In the survival analysis, patients with postoperative infection had significantly worse overall survival than patients without postoperative infection. The median survival times were 21.9 and 33.0 months (P = .023), respectively, for patients with and without postoperative infection. According to the multivariate analysis for overall survival, lack of adjuvant therapy (P = .002), but not postoperative infection (P = .829), predicted poor prognosis. The multivariate analysis revealed that postoperative infection (P < .001) was an independent risk factor for lack of adjuvant therapy. CONCLUSION: Postoperative infection in patients with pancreatic cancer may indirectly worsen the prognosis by preventing timely adjuvant therapy.

Incidence and outcomes of surgical site infection after cardiovascular surgery (complete republication).

OBJECTIVES: Surgical site infection in cardiovascular surgery had a great effect on postoperative outcomes. This study examined the current status of surgical site infection and postoperative outcomes used the registered data of the Japan Cardiovascular Surgery Database. METHODS: From the registry, we extracted 53,186 cases of thoracic cardiovascular surgery performed under median sternotomy in 2018. According to Japanese Healthcare Associated Infections Surveillance (JHAIS), patients were divided into three groups: coronary artery bypass graft (CABG) with saphenous vein graft (SVG) (SVG+ ; n = 14,246), CABG without SVG (SVG-; n = 5535), and operations other than CABG (no CABG; n = 33,405). The incidence of deep sternal wound infection, leg wound infection, hospital death, and hospitalization more than 90 days was examined. RESULTS: The incidence of deep sternal wound infection is 1.4% in all cases and 1.7% in SVG+ , 1.2% in SVG-, and 1.4% in no CABG. In deep sternal wound infection cases, incidence of hospital death was 24.7% and was higher than no infection cases. Especially, in no CABG group, incidence of hospital death was 30.1%. The long-term hospitalization rate and readmission rate within 30 days of patients with deep sternal wound infection were also high. CONCLUSIONS: The incidence of deep sternal wound infection was low, but it has not decreased. Postoperative outcomes in patients with surgical site infection were still bad.

Establishing clinical remission criteria and the framework of a treat-to-target algorithm for Takayasu arteritis: Results of a Delphi exercise carried out by an expert panel of the Japan Research Committee of the Ministry of Health, Labour and Welfare for intractable vasculitis.

OBJECTIVES: To develop a proposal for remission criteria and a framework for a treat-to-target (T2T) algorithm for Takayasu arteritis (TAK). METHODS: A study group of the large-vessel vasculitis group of the Japanese Research Committee of the Ministry of Health, Labour and Welfare for Intractable Vasculitis consists of 10 rheumatologists, 5 cardiologists, 1 nephrologist, 1 vascular surgeon, 1 cardiac surgeon, and 2 paediatric rheumatologists. A Delphi survey of remission criteria items was circulated among the study group over four reiterations. To develop the T2T algorithm, the study group conducted four face-to-face meetings and two rounds of Delphi together with three patients. RESULTS: Initial literature review resulted in a list of 117 candidate items for remission criteria, of which 56 items with a mean score of ≥4 (0-5) were extracted including disease activity domains and treatment/comorbidity domains. The study group provided six overarching principles for the T2T algorithm, two recommendations on treatment goals, five on evaluation of disease activity and imaging findings including positron emission tomography-computed tomography, and two on treatment intensification. CONCLUSIONS: We developed a T2T algorithm and proposals for standardised remission criteria by means of a Delphi exercise. These will guide future evaluation of different TAK treatment regimens.

[Treatment Strategy for Aortic Arch Aneurysms to Minimize the Complications:Which should be Chosen, Endovascular Treatment or Open Repair?]

The technologies of endovascular treatment for aortic pathologies have progressed rapidly, and endovascular treatment for thoracic pathologies has gained widespread acceptance, and there has been a significant increase in the number of thoracic pathologies treated by thoracic endovascular aortic repair (TEVAR) over the last decade. The initial results of TEVAR such as operative mortality and morbidities have been good and acceptable. Therefore, indication of TEVAR has expanded along with the improvement of techniques and devices. However, as its mid-term and long-term results became available, complications including stroke, endoleaks and consequent aneurysm rupture have become apparent. Open repair is still the important treatment option because its results are acceptable and durable. This article provides an treatment strategy of aortic arch aneurysms to minimize the complications.

Intraoperative collection of autologous platelet-rich plasma from the cardiopulmonary bypass circuit upon initiation of extracorporeal circulation.

OBJECTIVES: The aim of this study is to evaluate the possibility of the autologous platelet-rich plasma (PRP) collection from the cardiopulmonary bypass (CPB) circuit and to evaluate its effect on the aggregative function. METHODS: For seventy-two patients undergoing cardiac surgery with CPB, an autologous PRP was prepared using the Haemonetics Component Collection System® by drawing blood from the CPB circuit immediately after CPB was established. The blood samples were taken at three points for examination, A: beginning of surgery, B: immediately after heparin reversal with protamine following discontinuation of CPB, C: after the collected autologous PRP was returned to the patient. Platelet count and platelet aggregation ability were analyzed. RESULTS: The mean platelet count in autologous PRP was 5.5 (range: 3-14) units. Platelet count decreased by 115.0 (±27.3) × 1000/µl from A to B and increased by 27.3 ± 17.2 (× 1000/µl) from B to C. When platelet aggregation was measured by Adenosine Diphosphate (ADP) 3.0 µM, it decreased by 42.6% ± 12.1% from A to B and increased by 8.7% ± 7.4% from B to C. CONCLUSIONS: Autologous PRP can be safely collected by drawing blood from the CPB circuit, platelet count and aggregation ability significantly decreased after CPB including autologous PRP collection. Some improvement was detected in the number of the platelets count and platelet aggregation ability by administrating an autologous PRP even if autologous PRP is collected from CPB circuit. TRIAL REGISTRATION: UMI-CTR, UMIN000023776 . Registered 1 October 2016.

Impact of postoperative remote infection on length of stay and medical costs in hospitals in Japan.

PURPOSE: To analyze the impact of postoperative remote infections (PRIs) on medical expenditure. METHODS: The subjects of this retrospective study were 338 patients who had undergone gastroenterological surgery at one of the 20 Japanese institutions within the Japan Society for Surgical Infection (JSSI) and mainly authorized as educational institutions. The patients were allocated to 169 pairs of those with a PRI (PRI (+) group) matched with those without a PRI (PRI (-) group). PRIs included pneumonia, urinary tract infection (UTI), catheter-associated blood stream infection (CA-BSI), and antibiotic-associated enteritis. RESULTS: SSI developed in 74 of the 338 patients (22 without PRI and 52 with PRI). The SSI incidence was significantly higher in the PRI (+) group (p < 0.001). The difference in the median postoperative length of hospital stay was 15 days, indicating a significant prolongation in the PRI (+) group (p < 0.001). The PRI (+) group also had a higher rate of inter-hospital transfer (p < 0.01) and mortality (p < 0.001). Similarly, the difference in median postoperative medical fees was $6832.3, representing a significant increase in the PRI (+) group (p < 0.001). CONCLUSIONS: The postoperative length of hospital stay is longer and the postoperative medical expenditure is higher for patients with a PRI than for those without a PRI.

Treatment of ventricular septal perforation caused by blunt trauma using the right ventricle approach: A case report.

Traumatic ventricular septal perforation (VSP) is a rare condition that can occur following chest trauma and can lead to heart failure. Herein, a case of VSP caused by blunt chest trauma successfully closed using the double-patch technique via the right ventricle after medial sternotomy is presented. This case report highlights the necessity of emergency surgery in the acute phase of traumatic VSP if heart failure is difficult to control. This technique was useful for acute surgery. .

Current Trends in Epidemiology and Clinical Features of Thromboangiitis Obliterans in Japan　- A Nationwide Survey Using the Medical Support System Database.

BACKGROUND: The epidemiology and clinical features of thromboangiitis obliterans (TAO) in Japan have not been updated extensively.Methods and Results:This retrospective study used the Japanese Ministry of Health, Labour and Welfare (JMHLW) medical support system database and associated health insurance data. The number of medical financial support recipients registered as TAO patients and estimated prevalence of TAO decreased from fiscal year (FY) 2000 (10,089 and 7.95 [95% confidence interval, CI: 7.79-8.10] per 100,000 population) to FY 2010 (7,147 and 5.58 [95% Cl: 5.45-5.71] per 100,000) and leveled off until 2014. The prevalence of TAO among patients with peripheral arterial occlusive diseases declined from 7.15% (95% Cl: 7.00-7.31) in FY 2008 to 6.12% (95% Cl: 5.98-6.26) in FY 2014. Clinicodemographic features were obtained from 89 new recipients in FY 2013 and 2014: 12 (13%) women, 36 (40%) aged ≥50 years, 26 (29%) had probable onset age ≥50 years, 7 (8%) were non-smokers, and 12 (13%) had arteriosclerosis-related comorbidities. The symptoms were similar regardless of registration age, smoking history, or sex. Although 40 (45%) had digit ulcers, only 12 (13%) fulfilled Shionoya's criteria. They rarely had infrapopliteal lesions combined with upper extremity involvement or phlebitis. CONCLUSIONS: The prevalence of TAO has decreased in Japan. In the current diagnosis of TAO, various clinical characteristics including late onset, arteriosclerotic factors, non-smoking, or mild symptoms should be considered.

Local administration of the powder minocycline during surgical intervention for active infective endocarditis.

OBJECTIVES: We retrospectively assessed the initial clinical impact of the locally administered bacteriostatic antibiotic, powder minocycline, during surgery for active infective endocarditis (AIE). METHODS: Among 38 surgical AIE patients, 36 patients who underwent surgical intervention for AIE using local administration of powder minocycline between January 2008 and August 2017 in our institute were enrolled. During surgery, the local administration and dispersion of powder minocycline at not only the valvular annulus and perivalvular cavity, but also the prosthetic cuff and ring were performed following the complete resection and aggressive debridement of infectious tissues. Early clinical outcomes, including survival, postoperative co-morbidities, and freedom from re-intervention or significant paravalvular leakage (PVL), were assessed. RESULTS: Early mortality within 30 days was 5.6% and hospital death was 13.9%. There was no reoperation within 30 days and only one patient (3.8%) developed recurrent infection, which improved with additional antibiotic treatments. More than moderate PVL within 30 days was detected in one patient only (3.8%). Over a median follow-up period of 38.3 ± 35.5 months, a Kaplan-Meier analysis revealed that 1- and 5-year survival rates were 75.7 and 66.8%, respectively, and freedom from reoperation was 100% at 5 years. Freedom from significant PVL at 5 years was 91.0%. CONCLUSIONS: The local administration of powder minocycline may be a simple and effective manipulation during surgical intervention for AIE without extensive reconstruction; however, the surgical management of AIE remains challenging.

Surgical management of large undifferentiated cardiac sarcoma involving the right ventricle to pulmonary trunk.

A large intra-cardiac tumor from the right ventricle to pulmonary trunk was detected by contrast-enhanced computed tomography and transthoracic echocardiography in a 59-year-old woman with progressive dyspnea on effort and acute congestive right-sided heart failure. Emergent surgical management was performed with cardiopulmonary bypass under cardiac arrest, however, tumor resection was incomplete, because it originated from the interventricular septum. Concomitant tricuspid valve replacement using a bioprosthesis was required due to the involvement of the septal leaflet of the tricuspid valve. Although large pulmonary thromboembolism was initially suspected, a pathological examination confirmed undifferentiated cardiac sarcoma. The patient did not consent to additional neoadjuvant chemotherapy or radiation therapy. After palliative surgical management, she was discharged. Recurrence rapidly progressed and the patient died approximately 2 months after surgery. We herein present a successful palliative surgical case of large cardiac undifferentiated sarcoma originating from the intraventricular septum and involving the right ventricle to pulmonary trunk.

Angiographic appearance of patent saphenous vein grafts more than 25 years after coronary artery bypass grafting.

Nine patients with ten angiographical patent saphenous vein grafts (SVG) more than 25 years after coronary artery bypass grafting (CABG) at Kawasaki Medical School Hospital between 1976 and 1992 were reviewed. Patent SVG disease was assessed using the FitzGibbon classification, and clinical characteristics which might affect the longevity of SVG were retrospectively evaluated. The mean duration between surgery and current coronary angiography was approximately 30 years (25-35 years). There were two perfectly patent SVGs (FitzGibbon AI, 35 and 32 years after surgery), both of which were bypass grafts to the left anterior descending arteries (LAD). The other eight grafts exhibited some vein graft disease (BII:3, BIII:5). The sequential anastomosis was performed for 5 SVGs. The SVGs bypassed to the good run-off LAD, sequential bypass, strict medical management including cessation of smoking and body weight control may contribute to the slow progression of vein graft disease after CABG.

A surgical case of triple valve replacement for triple valve endocarditis with multiple vegetations.

A 68-year-old man with cerebral infarction and right hemiplegia was diagnosed with active infective endocarditis, and multiple large vegetations and more than moderate valve regurgitation by three different valves were detected using transthoracic echocardiography. An urgent surgical intervention was selected, and aortic and mitral valve replacements using bioprostheses were initially performed due to large vegetation on both these valves with valve cusp destruction. Residual severe regurgitation persisted despite tricuspid valve plasty; therefore, tricuspid valve replacement using a tissue valve was performed, and triple valve replacement was eventually accomplished without any serious hemodynamic compromise. The postoperative clinical course was fair and the patient was discharged after 3 months of inpatient strict management and cardiac rehabilitation. However, he died approximately 9 months after the initial surgery due to multiple organ failure. We herein presented a rare surgical case of triple valve replacement for triple valve endocarditis with multiple large vegetations.

Patient trends and outcomes of surgery for type A acute aortic dissection in Japan: an analysis of more than 10 000 patients from the Japan Cardiovascular Surgery Database.

OBJECTIVES: To evaluate the background trends and surgical outcomes for more than 10 000 patients with acute type A dissection in Japan in a recent 8-year period. METHODS: Data on replacement of the ascending aorta and/or aortic arch for acute type A dissection were collected from the Japan Cardiovascular Surgery Database from 2008 to 2015. Linear-by-linear association tests or Cuzick's test for trend was used to evaluate group trends over time. The results were calculated for ascending or hemiarch replacement and arch replacement. A multivariable logistic regression model was used to calculate the risk-adjusted operative mortality rate. RESULTS: A total of 11 843 patients were included. The overall 30-day mortality and operative mortality rates were 7.6% and 9.5%, respectively. The number of surgically treated cases increased from 2436 patients in 2008-2009 to 3533 in 2014-2015, a 45.0% increase. A trend analysis revealed significant changes in patient characteristics with time, including increasing age and rate of preoperative renal failure. Despite worsening risk factors, the unadjusted operative mortality rate with arch replacement showed a significant downward trend (P = 0.01; test of trend). The risk-adjusted mortality rate showed a downward trend both in ascending aorta or hemiarch replacement and arch replacement, although the trend was not statistically significant (P > 0.05). CONCLUSIONS: Unadjusted and adjusted operative deaths have shown a decreasing trend, although patients undergoing surgery for acute type A dissection have demonstrated worsening of risk factors, such as age and renal failure. The number of surgeries performed for acute type A dissection significantly increased throughout the study period in Japan.