Occurrence and incidence rate of peripheral intravascular catheter-related phlebitis and complications in critically ill patients: a prospective cohort study (AMOR-VENUS study).

BACKGROUND: The lack of precise information on the epidemiology of peripheral intravascular catheter (PIVC)-related phlebitis and complications in critically ill patients results in the absence of appropriate preventive measures. Therefore, we aimed to describe the epidemiology of the use of PIVCs and the incidence/occurrence of phlebitis and complications in the intensive care unit (ICU). METHODS: This prospective multicenter cohort study was conducted in 23 ICUs in Japan. All consecutive patients aged ≥ 18 years admitted to the ICU were enrolled. PIVCs inserted prior to ICU admission and those newly inserted after ICU admission were included in the analysis. Characteristics of the ICU, patients, and PIVCs were recorded. The primary and secondary outcomes were the occurrence and incidence rate of PIVC-related phlebitis and complications (catheter-related blood stream infection [CRBSI] and catheter failure) during the ICU stay. RESULTS: We included 2741 patients and 7118 PIVCs, of which 48.2% were inserted in the ICU. PIVC-related phlebitis occurred in 7.5% (95% confidence interval [CI] 6.9-8.2%) of catheters (3.3 cases / 100 catheter-days) and 12.9% (95% CI 11.7-14.2%) of patients (6.3 cases / 100 catheter-days). Most PIVCs were removed immediately after diagnosis of phlebitis (71.9%). Grade 1 was the most common phlebitis (72.6%), while grade 4 was the least common (1.5%). The incidence rate of CRBSI was 0.8% (95% CI 0.4-1.2%). In cases of catheter failure, the proportion and incidence rate per 100 intravenous catheter-days of catheter failure were 21% (95% CI 20.0-21.9%) and 9.1 (95% CI 8.7-10.0), respectively. CONCLUSION: PIVC-related phlebitis and complications were common in critically ill patients. The results suggest the importance of preventing PIVC-related complications, even in critically ill patients. TRIAL REGISTRATION: UMIN-CTR, the Japanese clinical trial registry (registration number: UMIN000028019 , July 1, 2017).

Impact of Complete Revascularization on Long-Term Outcomes After Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction.

BACKGROUND: The long-term outcomes of complete revascularization (CR) in patients with left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) remain unclear. Methods and Results: We evaluated a consecutive series of 111 patients with LV ejection fraction ≤35% who underwent isolated first-time CABG: 63 underwent CR and 48 underwent incomplete revascularization (IR). At a median follow-up of 10.1 years, the rates of death from any cause, cardiac death, and major adverse cardiac and cerebrovascular events (MACCE) were significantly greater in the IR group. After adjusting for propensity score, no significant difference was found between the CR and IR groups regarding death from any cause (hazard ratio [HR], 1.45; 95% CI: 0.75-2.81; P=0.271) and cardiac death (HR, 1.45; 95% CI: 0.68-3.10; P=0.337). In contrast, IR increased the risk of MACCE (HR, 1.92; 95% CI: 1.08-3.41; P=0.027), which was principally attributed to an increased risk of repeat revascularization (HR, 3.92; 95% CI: 1.34-11.44; P=0.013). CONCLUSIONS: Although IR was not significantly associated with an increased risk of long-term mortality in patients with LV dysfunction who underwent CABG, CR might reduce the risks of repeat revascularization and subsequent MACCE.

Coronary artery spasm following off-pump coronary artery bypass surgery.

Coronary artery spasm after coronary artery bypass surgery may result in life-threatening arrhythmias, circulatory collapse, or death. We report two cases of coronary artery spasm after coronary artery bypass surgery, one of which developed ventricular fibrillation requiring extracorporeal membrane oxygenation support. Both patients were discharged in good condition and are currently followed as outpatients. Unexpected sudden hemodynamic compromise could be due to coronary vasospasm, and this should be considered as one of the possible differential diagnoses. We were able to prevent the lethal consequences seen with coronary artery spasm by early diagnosis and management.

Intraoperative assessment for mitral valve competency in a beating heart under retrograde coronary perfusion.

Intraoperative assessment of a repaired mitral valve is of paramount importance for reparative mitral surgery. From September 2010 through November 2012, 20 consecutive patients underwent mitral valve plasty for mitral regurgitation. The patients who underwent surgery after June 2012 received assessment of the repair with the heart beating (HB group, n = 10), and the patients who underwent the operation before May 2012 were assessed for the repair only under cardioplegic heart arrest (non-HB group, n = 10). Intermittent cold retrograde blood cardioplegia was used in all patients. In the HB-group, after completion of the procedures, pump blood without a crystalloid additive was delivered into the coronary sinus. The function of the mitral valve was assessed under beating conditions. There were no differences between the two groups in aortic cross clamp time and operation time, although operative and concomitant procedures were slightly more complicated in the HB group than in the non-HB group. Postoperative echocardiography revealed none or mild mitral regurgitation in all the patients in both groups. Reopening of the closed left atrium for additional repair was necessary only in one patient in the HB group and 3 patients in the non-HB group. In conclusion, the method of perfusing the myocardium retrogradely via the coronary sinus with warm blood is safe and effective for assessing the competency of the mitral valve in a beating heart.

Repeated mitral valve replacement in a patient with extensive annular calcification.

BACKGROUND: Mitral valve replacement in the presence of severe annular calcification is a technical challenge. CASE REPORT: A 47-year-old lady who had undergone mitral and aortic valve replacement for rheumatic disease 27 years before presented with dyspnea. At reoperation, extensive mitral annular calcification was hindering the disc motion of the Starr-Edwards mitral prosthesis. The old prosthesis was removed and a St Jude Medical mechanical valve was implanted after thorough annular debridement. Postoperatively the patient developed paravalvular leak and hemolytic anemia, subsequently undergoing reoperation three days later. The mitral valve was replaced with an Edwards MIRA valve, with a bulkier sewing cuff, after more aggressive annular debridement. Although initially there was no paravalvular leak, it recurred five days later. The patient also developed a small cerebral hemorrhage. As the paravalvular leak and hemolytic anemia gradually worsened, the patient underwent reoperation 14 days later. A Carpentier-Edwards bioprosthetic valve with equine pericardial patches, one to cover the debrided calcified annulus, another as a collar around the prosthesis, was used to eliminate paravalvular leak. At 7 years postoperatively the patient is doing well without any evidence of paravalvular leak or structural valve deterioration. CONCLUSION: Mitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.

Long term results with the Cabrol aortic root replacement.

Cabrol aortic root replacement is rarely performed in recent years because of potential coronary complications. The purpose of this study was to investigate its early and late results, including coronary complications, by evaluating our experience thus far. A retrospective lookup of patients who underwent Cabrol aortic root replacement between 1988 and 2001 found a total of 36 patients (24 men and 12 women) with a mean age of 45 years. Annuloaortic ectasia was the most frequent cause (n = 22), followed by chronic dissection (n = 5), acute dissection (n = 5), and aneurysm with prior aortic operation (n = 4). Early mortality occurred in one patient (2.8%). The mean follow-up period was 104 months. There were 7 late deaths, 4 of which were disease-related. The actuarial survival was 83.3% at 5 years and 72.9% at 10 years, and the freedom from reoperation was 87.9% at 5 years and 76.6% at 10 years. There were no reoperations on the ascending aorta. Coronary ostia were examined by angiography or 64-row multidetector computed tomography in 18 patients 43 to 189 months after the operation. Two patients developed stenosis or occlusion of the right coronary ostium. The early and late results of the Cabrol operation were favorable with the exception of coronary complications. The importance of careful follow-up for late coronary complications cannot be overemphasized.

[Acute forearm compartment syndrome after total arch replacement].

A 61-year-old female presented with shortness of breath and was found to have moderate aortic regurgitation with annulo-aortic ectasia and an aneurysm involving the aortic arch. She underwent Bentall operation and total arch replacement with a branched prosthesis. The patient developed hypesthesia and paresis of the left forearm one day after the surgery. Computed tomography revealed complete occlusion of the left subclavian artery (LSA). An emergency operation was performed 15 hours after the initial operation. A new bypass graft to the axillary artery was placed since the LSA was occluded by the wide arterial dissection. However, her left forearm showed rapid swelling within a few hours. Under the diagnosis of acute compartment syndrome (ACS) of the forearm, emergency decompression fasciotomy was performed. She was discharged with a mild dysfunction of her forearm and hand 40 days after the operation. The rapid progression of ACS was thought to have been associated with not only the severe and prolonged ischemia but also the venous obstruction caused by the ligation of left brachiocephalic vein during the initial operation. Immediate and complete decompression, including the deep compartment of the forearm, was essential to achieve a full functional recovery from ACS.

[Heparin-induced thrombocytopenia after on-pump coronary artery bypass grafting].

We report herein a case of a patient who suffered heparin-induced thrombocytopenia (HIT) after on-pump coronary bypass grafting (CABG). A 62-year-old woman had received coronary angiography with heparin 4 months before CABG. She had been given heparin for 7 days before CABG, and underwent the operation under cardiopulmonary bypass uneventfully. She experienced thrombosis of multiple vein grafts without deep venous thrombosis or pulmonary embolism postoperatively. During percutaneous coronary intervention for residual coronary stenoses, acute multiple thromboses in coronary stents developed. We suspected HIT and administered argatroban instead of heparin. She recovered from shock after intra-aortic balloon pump insertion and balloon angioplasty for in-stent thromboses. HIT should be suspected whenever a thrombosis suddenly occurs in perioperative cardiac patients. Early diagnosis and treatment for HIT is essential to prevent subsequent thromboembolic events.

Mid-term results of a closed biatrial procedure using bipolar radiofrequency ablation concomitantly performed with non-mitral cardiac operations.

The long-term success rate of the Cox maze III procedure is excellent, although it has not been widely adopted because of the need for extensive incisions of the atria. In this study, we report our experience with a closed biatrial procedure using bipolar radiofrequency (RF) ablation for treating atrial fibrillation (AF) during non-mitral cardiac operations. Beginning in December 2004, a total of 19 patients underwent a closed biatrial procedure with bipolar RF energy. All the patients had a maze procedure plus a concomitant non-mitral operation. Except for several stabs to introduce the bipolar device, no incisions were made in either atrium. The first six patients were investigated with 64-slice multidetector computed tomography (MDCT), six months after the operation. Patients were followed-up monthly with a clinical examination and electrocardiography. There were no operative deaths. MDCT showed no evidence of coronary sinus stenosis. At one year of follow-up, 93% of the patients (14/15) were in sinus rhythm. The closed biatrial procedure using bipolar RF ablation is safe and effective in treating AF during open-heart surgery. This could be particularly beneficial for patients with AF who are undergoing a cardiac surgical procedure without opening the left atrium.

Concomitant aortic valve-sparing operation and closed biatrial radiofrequency ablation for annuloaortic ectasia and paroxysmal atrial fibrillation.

A 53-year-old woman was admitted for annuloaortic ectasia with moderate aortic valve insufficiency (AI) and paroxysmal atrial fibrillation. Concomitant aortic root replacement with a valve-sparing technique and closed biatrial procedure using bipolar radiofrequency ablation was performed successfully. Postoperative echocardiography showed trivial AI with regular sinus rhythm, which meant she could avoid anticoagulation therapy.

Off-pump coronary artery bypass grafting in a patient with Werner's syndrome.

Werner's syndrome is a rare hereditary disorder that is characterized by premature aging. We report a case of off-pump coronary artery bypass grafting (OPCAB) in a 56-year-old man with Werner's syndrome. We used an endoscopic vessel-harvesting system to harvest great saphenous vein grafts (SVGs) because this system helps minimize surgical wounds. This is important because poor wound healing is a prominent feature of Werner's syndrome. Revascularization of the coronary arteries in this case was thought to improve his prognosis, although he had already outlived the average life-span of Werner's syndrome. A detailed examination of the cardiovascular system should be performed in patients with this disorder.

[Evaluation of paravalvular leakage occurring after the 3rd mitral valve replacement].

We evaluated the frequency of paravalvular leakage (PVL) in 21 patients who had undergone mitral valve replacement (MVR) 3 times or more in our department between January 1981 and December 2003. Of these 21 patients, 5 underwent MVR 4 times, including the one who underwent the 5th MVR. Seven (38%) of 18 patients who had successfully undergone MVR 3 times and all 2 patients who had successfully undergone MVR 4 times developed PVL. PVL recurred in 6 (67%) of 9 patients who had undergone the 3rd MVR due to the occurrence of PVL. However, PVL recurred in only 1 (11%) of 9 patients who had undergone the 3rd MVR due to some postoperative complications other than PVL. Among 10 patients who developed PVL after the 1st or 2nd MVR, PVL recurred in 7 patients after the 3rd MVR. However, among 8 patients who did not develop PVL after the 1st or 2nd MVR, PVL occurred after the 3rd MVR only in 1 patient. These findings suggest that repeated MVR increases the incidence of PVL, and that patients with a past history of PVL are at a higher risk of developing PVL after repeated MVR.

Papillary fibroelastoma of the left ventricle: report of two cases.

Papillary fibroelastoma is a relatively rare cardiac tumor. We report two cases of papillary fibroelastoma. The first case involved a 45-year-old woman who presented with rheumatic valves and three tumors developing from the papillary muscle and left ventricle. The second case involved a 68-year-old man who was asymptomatic and whose tumor was detected incidentally on echocardiogram. Both cases were treated surgically. An additional 71 cases of papillary fibroelastoma reported in the medical literature in Japan are reviewed.

Evaluation of coronary artery bypass grafts and native coronary arteries using 64-slice multidetector computed tomography.

BACKGROUND: The conventional use of 16-slice multidetector computed tomography (MDCT) remains somewhat limited for evaluating stenoses in vein graft distal anastomotic sites and in coronary arteries. We investigated the diagnostic accuracy of 64-slice MDCT for assessment of both grafts and coronary arteries in patients with coronary artery bypass grafts. METHOD: The study group included 54 consecutive patients. One patient had to be excluded from the study because of arrhythmia. The remaining 53 patients with coronary artery bypass grafts underwent both 64-slice MDCT angiography and invasive coronary angiography. The MDCTs were analyzed for presence of significant stenosis (>50%) or occlusion in grafts and coronary arteries. The results were compared with those of invasive coronary angiography. RESULTS: Overall, 138 of 146 (94.5%) grafts including distal anastomoses were evaluable with MDCT. Evaluability of arterial grafts, venous grafts, distal runoff arteries, and nongrafted arteries was 90.3%, 98.6%, 84.0%, and 97.3%, respectively. After censoring nonevaluable grafts or arteries and considering them to be positive, the sensitivity to detect significant stenosis or occlusion in arterial grafts was 100% and specificity was 91.4%. In venous graft, sensitivity was 100% and specificity was 98.1%. In distal runoff arteries, sensitivity to detect significant stenoses was 83.3% and specificity was 80.2%. In nongrafted arteries, sensitivity was 100% and specificity was 87.5%. CONCLUSIONS: Sixty-four-slice MDCT showed improved ability to assess bypass grafts and coronary arteries. However, there were still difficulties in assessment of distal runoff arteries in which relatively low diagnostic accuracy was observed that might limit clinical implementation of MDCT.

Preoperative angiographic evaluation of the descending branch of the lateral femoral circumflex artery as a free graft in coronary artery bypass graft.

OBJECTIVES: The purpose of this study is to assess by angiogram, the availability and variety of descending branches of the lateral femoral circumflex artery in coronary artery bypass graft. METHODS: The diameter and length were measured by angiogram in 70 cases. Descending branches of the lateral femoral circumflex artery greater than 8 cm in length and a diameter over 2 mm were judged as available for coronary artery bypass graft. Comparisons were performed between the right and left, and in some cases, between the length by angiogram and intraoperatively. RESULTS: Forty-eight cases (68.6%) were judged suitable for bypass. Twenty-one were suitable for bypass only on the right, 6 only on the left, and 21 were suitable for either side. In total, 33 descending branches of lateral femoral circumflex arteries were used. Reasons for exclusion were; existence of wall irregularity and/or stenosis (15.7%), medial position (12.9%), hypoplasty (10.0%), unidentified (8.6%), and insufficient imaging (5.7%). The diameter of the right side was significantly larger than the left (3.6 vs. 3.3 mm, p<0.01). In 21 cases, the length of the harvested descending branches of the lateral femoral circumflex artery measured intraoperatively was 10.8 cm (5 to 18 cm), that was 91% of the length measured by angiogram, and the lumen diameter was 3.2 mm in proximal, 2.3 mm in distal. CONCLUSION: As the availability of descending branches of the lateral femoral circumflex artery is limited and some varieties are recognized, preoperative angiogram is strongly recommended when it is planned for coronary artery bypass graft.

Clinical outcome of percutaneous transluminal coronary rotational atherectomy in patients with end-stage renal disease.

The clinical results of percutaneous transluminal coronary rotational atherectomy (PTCRA) in dialysis patients were retrospectively evaluated in comparison with coronary artery bypass grafting (CABG). From 1997 to 2001, 44 consecutive dialysis patients with 61 lesions underwent PTCRA and 55 consecutive dialysis patients underwent CABG. The initial success rate of PTCRA was 98%. The PTCRA group had a shorter hospital stay (13+/-17 vs 60+/-35 days, p=0.0001) and a lower rate of complications (11% vs 42%, p=0.001) than the CABG group. Although neither event-free survival without death nor myocardial infarction (MI) was significantly different between the CABG and PTCRA groups during the mean follow-up period of 21+/-14 months, 20 patients (45%) in the PTCRA group needed repeat revascularization of the target lesion. In conclusion, PTCRA may be a safe alternative modality for revascularization of high-risk CABG candidates, with excellent short-term results although the long-term outcome is inferior to that of CABG because of the higher restenosis rate.