Infrainguinal Lesion of Peripheral Artery Disease and Levels of ω-3 Polyunsaturated Fatty Acids in Peripheral Artery Disease.

Background: Recently, reduced serum levels of ω-3 polyunsaturated fatty acids (PUFAs) including docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), have been focused upon as newly recognized risk factors for peripheral artery disease (PAD). The present study investigated the association between disease location and serum levels of ω-3 PUFAs in patients with PAD. Methods: We retrospectively analyzed the data of patients at Tokyo Medical University between August 2011 and November 2015. The subjects included 98 patients who were categorized into two groups: those with (n=72) and without infrainguinal lesions (n=26). Results: Univariate analysis revealed that low ankle-brachial pressure index (ABI) values, low EPA levels, low DHA levels, low triglyceride levels, and diabetes mellitus were significant risk factors for infrainguinal lesions. Multivariate analysis indicated that low ABI values [p=0.018; odds ratio, 0.043; 95% confidence interval (CI), 0.003-0.579] and low DHA levels (p=0.003; odds ratio, 0.986; 95%CI, 0.977-0.995) were significant independent risk factors for infrainguinal lesions. Conclusion: Our study demonstrated that reduced serum level of DHA may underlie the presence of infrainguinal lesions in patients with PAD.

Effects of short-term administration of tolvaptan after open heart surgery.

BACKGROUND: Postoperative fluid overload following cardiac surgery is associated with increased morbidity and mortality. Unlike loop diuretics, tolvaptan (TLV) promotes aquaretic effect. Relatively little has been documented regarding the efficacy of TLV after cardiac surgery. The aim of the study was to investigate the effectiveness and safety of tolvaptan for the management of immediately postoperative fluid retention following cardiac surgery. METHODS: Between January to May 2014, patients undergoing cardiac surgery were randomly assigned to control or TLV group immediately after cardiac surgery. In control group, patients received 20mg of furosemide and 25mg of spironolactone as conventional diuretics. In the TLV group, 7.5mg of TLV was administered in combination with conventional diuretics. RESULTS: TLV use was associated with increased urine output from postoperative day 1 to 3.Body weight reduction in the TLV group was significantly greater than the control group from postoperative day 2 to 4, and serum creatinine levels decreased to below preoperative values in the TLV group. CONCLUSIONS: The combination of tolvaptan with conventional diuretics increases urine output without renal dysfunction and can be effective for postoperative fluid management and appropriate body weight reduction.

Management of Failed Crossover Stenting across the Ostium of the Deep Femoral Artery: Report of 2 Cases.

Little is known regarding the consequences of bifurcation patency loss after failed crossover superficial femoral artery (SFA) stenting. We report on 2 cases concerning patients presenting with acute and chronic symptoms of critical limb ischemia after failed crossover SFA stenting and undergoing open surgical repair. We discuss the risk and management of failed crossover SFA stenting.

Sternal closure by rigid plate fixation in off-pump coronary artery bypass grafting: a comparative study.

Sternal instability or dehiscence results in serious sternal wound infection. We sought to assess the early outcomes with such a plating system for sternal closure in comparison to the conventional wiring technique in off-pump coronary artery bypass grafting (CABG). Patients who underwent off-pump CABG were enrolled. Thirty-one patients received plate sternal fixation. A total of 64 patients who underwent off-pump CABG by a single surgeon at our hospital from July 2013 to December 2014 were enrolled. Thirty-one patients received plate sternal fixation (Plate group), while 33 received conventional wire closure (Wire group). The early outcomes, including the pain score and analgesic usage count were compared. Dietary intake was also recorded to assess the duration of appetite loss. At discharge, the largest sternal displacement was measured on computed tomography. In the Plate group, the pain scores were significantly lower on post-operative day 5-8 and POD 9-12 from those in the Wire group. The analgesic usage count on POD 9-12 was significantly lower in the Plate group. The duration of appetite loss and hospital stay was significantly shorter in the Plate group. The displacement in both the anterior-posterior and lateral directions was significantly smaller in the Plate group. Sternal closure by rigid plate fixation contributes to a more rapid post-operative recovery through reduced pain.

Difficulty in the management of anticoagulation with argatroban during off-pump coronary artery bypass grafting.

Heparin-induced thrombocytopenia (HIT) can often result in devastating thromboembolic outcomes. Argatroban is frequently administered as an alternative anticoagulant to heparin. We present a complicated case of HIT in which off-pump coronary artery bypass grafting was performed using anticoagulation with argatroban. Although the active clotting time was maintained between 220 and 270 s using argatroban, intraoperative thrombotic complications and postoperative prolonged coagulopathy were encountered. .

Bilateral coronary ostial stenosis and aortic regurgitation in a patient with cardiovascular syphilis.

Cardiovascular syphilis is associated with the tertiary stage of syphilis infection; it involves the ascending aorta and can cause aortic aneurysm, aortic regurgitation, and coronary ostial stenosis. We report a surgical case of bilateral coronary ostial lesion and aortic regurgitation due to syphilitic aortitis. .

[Repented Bentall operation for the case of aortitis with totally calcified ascending aortic allograft].

A 49-year-old male underwent re-do root Bentall operation with aortic allograft for the prosthetic valve detouchment due to aortitis syndrome 15 years ago (reported in 1998). He was presented with the hemolytic anemia due to severe aortic stenosis. The totally calcified aortic allograft was found by the computed tomography and chest X-ray. The allograft severely migrated to the sternum was approached by re-sternotomy under the circulatory arrest following the establishment of cardiopulmonary circulation and the 2nd-re-operation of root replacement was performed with composite graft with mechanical heart valve. He was discharged on foot on the 46th postoperative day. A tight follow-up is necessary for such a case of aortitis syndrome.

Volume reduction rate by surgical ventricular restoration determines late outcome in ischaemic cardiomyopathy.

AIMS: Surgical ventricular restoration (SVR) effectively reduces left ventricular (LV) volume in ischaemic cardiomyopathy (ICM), but the recent Surgical Treatment of Ischemic Heart Failure (STICH) Trial questions its importance. We report 8-year SVR experience in patients with ICM. METHODS AND RESULTS: Between 2000 and 2008, 135 patients underwent SVR for ICM. This report analyses data from 90 patients who underwent accurate pre- and post-operative assessment of LV volumes by left ventriculogram or scintigram. All patients also had echocardiograms. Pre-operative LV end-systolic volume index (ESVI) was 123.5 ± 53.2 mL/m(2) (range 92-310). Overall, 63 patients were in NHYA class III and 27 were in class IV. The SVR procedure was endoventricular circular patch plasty in 33 patients, septal-anterior ventricular exclusion in 43, and 14 patients had posterior exclusion. Coronary artery bypass grafting was performed in 78 patients (87%) and 50 underwent mitral procedures. Eighteen follow-up late deaths occurred owing to chronic heart failure (n = 12) and sudden death (n = 6). Post-operative ESVI was < 90 mL/m(2) (Group-S) in 54 patients, 90-120 mL/m(2) (Group-M) in 16, and >120 mL/m(2) (Group-L) in 20 patients. The 8-year survival rate was 82.4% in group-S following a > 33% LV volume reduction. In contrast, in Group-M and Group-L, the volume reduction was ∼ 15%, and 100% of patients died within 7 years following the SVR procedure (or 0% 8-year survival). CONCLUSIONS: SVR is most effective when a >33% volume reduction rate achieves an ESVI of < 90 mL/m(2). No long-term benefits occur when SVR induces an LV volume reduction of < 15% leaving a residual ESVI >90 mL/m(2). This database contradicts the STICH trial findings.

[Saphenous vein graft aneurysm after coronary artery bypass grafting surgery presenting with chronic heart failure].

An 82-year-old woman with a history of a coronary artery bypass grafting (CABG) 10 years prior was admitted because of general fatigue, appetite loss and systemic edema. She presented with a right pericardial mass on chest radiography. Echocardiogram and computed tomography (CT) revealed a 6.0 x 7.0 cm saphenous vein graft aneurysm (SVGA) compressing both right atrium and the right ventricle. She was successfully treated with the aneurysmal resection and postoperative course was uneventful. Although SVGA is an unusual complication after CABG, we recommend that any patient with a history of previous CABG who presents with a mediastinal mass should be evaluated for possibility of SVGA.

[Surgical treatment for atrial fibrillation using ablation devices and ablation of autonomic ganglion plexi].

BACKGROUND: Development of ablation device for the surgical treatment for atrial fibrillation (Af) has suggested the safety and easiness of the maze procedure. However, the success rate of sinus rhythm (SR) recovery is not satisfactory. We studied the maze procedure and the results with ablation device and also with additional ganglion plexi (GP) ablation. PATIENTS AND METHODS: Since April in 2002, 269 patients received maze operation with ablation device. The etiology was valvular disease in 196, ischemic heart disease in 18, dilated cardiomyopathy (DCM) in 36, and others in 19. The full maze operation with ablation devices and cryoablation was performed in principle and monopolar ablation devices were used in early phase and the bipolar ablation device was applied thereafter. The 73 patients after October in 2007 were divided into 44 patients with simultaneous GP ablation and 29 patients without GP ablation and the recovery rate of SR was compared in the 2 groups. RESULTS: There were 7 hospital deaths (5 in DCM and 2 in valve disease). After the operation, 79% of the patients with monopolar devices and 75% of the patients with bipolar device were in SR. Among them, 88% of the patients with simultaneous GP ablation were in SR and no major complication. CONCLUSION: The full maze operation with bipolar ablation and cryoablation showed minimal operative risk and concomitant GP ablation improved the SR recovery rate after the operation.

Indication of posterior restoration and surgical results in patients with dilated cardiomyopathy.

OBJECTIVE: Nontransplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. Anterior restoration for anterior akinesis has shown favourable outcome. Posterior restoration and surgical results are also discussed. METHODS: At the Hayama Heart Center in Japan, between 2005 and 2009, posterior restoration for DCM was performed in 36 patients (10 with ischaemic and 26 with nonischaemic, including muscular dystrophy in three). There were 32 men and four women with a mean age of 53 years. The mean preoperative ejection fraction was 23% and the preoperative New York Heart Association (NYHA) classification was class III in 16 patients and class IV in 20 with eight emergent operations. To identify the posterior lesion before operation, speckle-tracking echocardiography was used, with a Vivid 7 ultrasound machine. The short-axis images from the middle level of the left ventricle (LV) were obtained to assess myocardial segmental viability. Based on the results of speckle-tracking echocardiography, posterior restoration was performed in patients with postero-lateral akinesis and septal kinesis. After the cardioplegic arrest, mitral plasty or coronary artery bypass grafting (CABG) was performed and the posterior LV muscle between bilateral papillary muscles was partially resected under beating heart. The LV apex was preserved and cryoablation was applied between the cut edge and the mitral annulus. All the patients were followed with cardiac echocardiography. RESULTS: In addition to LV restoration, mitral plasty was successfully performed in all the patients. Concomitant CABG was performed in seven, tricuspid surgery in 11 and cardiac resynchronisation therapy (CRT) in eight. Perioperative intra-aortic balloon pumping (IABP) was used in six and there was no hospital mortality, including eight emergent operations. After the operation, 29 patients (80.6%) improved their functional class into class I or II. In the late follow-up, there were two cardiac deaths and one noncardiac death and the 4-year survival rate was 85.8%. CONCLUSIONS: The site selection with speckle-tracking echocardiography demonstrated the accurate akinetic lesion of the posterior LV wall. The posterior restoration with preservation of bilateral papillary muscles and LV apex based on the site selection improved operative and mid-term results in the selected patients with DCM.