Simulation to determine the approach of transcatheter aortic valve implantation in patients undergoing hemodialysis.

PURPOSE: The present study investigated potential access vessels in patients receiving hemodialysis who underwent surgical aortic valve replacement and determined which approaches were most suitable for performing transcatheter aortic valve implantation. METHODS: Consecutive patients undergoing hemodialysis with aortic valve stenosis who underwent surgical aortic valve replacement were included. Preoperative computed tomography data were analyzed to assess the vessel diameter and calcification. Simulations were conducted to determine the feasibility of inserting the 14-F eSheath of Sapien 3 via transfemoral, trans-cervical, trans-subclavian, and direct aorta approaches. RESULTS: A total of 72 patients were included in this study. The access route was characterized by severe calcification of the common iliac artery. The transfemoral approach was feasible in 77.8% of the cases, but the rate decreased to 33% when the calculations were based on the maximum sheath extension diameter. The trans-cervical, trans-subclavian, and direct aortic approaches were suitable for many patients. Lower extremity artery disease was identified as a risk factor for the unsuitability of the transfemoral approach. CONCLUSIONS: Common iliac artery calcification in patients undergoing hemodialysis restricts the use of the transfemoral approach. Therefore, some patients require alternative approaches.

Serum and Adipose Dipeptidyl Peptidase 4 in Cardiovascular Surgery Patients: Influence of Dipeptidyl Peptidase 4 Inhibitors.

Dipeptidyl peptidase 4 (DPP-4) is a novel adipokine and may be involved in the association between adipose tissue and metabolic syndrome. We investigated DPP-4 and adiponectin levels in the serum, subcutaneous adipose tissue (SAT), and epicardial adipose tissue (EAT), and their relationship with preoperative factors, as well as comparing the DPP-4 levels in SAT and EAT with and without DPP-4 inhibitors. This study included 40 patients (25 men, age 67.5 ± 13.8 years). The serum adipokine, DPP-4, and adiponectin levels in SAT and EAT were measured using ELISA and Western blotting. The DPP-4 and adiponectin levels were significantly higher in the SAT than in the EAT. The serum DPP-4 and DPP-4 activity levels had no correlation with the DPP-4 levels in the SAT and EAT, but the DPP-4 levels in the SAT and EAT had a positive correlation. The DPP-4 levels in the SAT were positively correlated with atherosclerosis, diabetes mellitus, DPP-4-inhibitor use, and fasting blood glucose. The DPP-4 levels in the EAT showed a negative correlation with eGFR and a positive correlation with atrial fibrillation. The DPP-4 activity in the serum had a lower tendency in the group taking DPP-4 inhibitors than in the group not taking them. DPP-4 inhibitors may suppress angiogenesis and adipose-tissue hypertrophy.

Mid-term results of surgical aortic valve replacement with bioprostheses in hemodialysis patients.

Background: Limited studies have assessed the factors affecting prognosis in hemodialysis (HD) patients who undergo surgical aortic valve replacement with a bioprostheses (SAVR-BP). This study aimed to evaluate the outcomes of HD patients who had undergone SAVR-BP for aortic stenosis (AS) and identify the risk factors for mortality. Methods: This retrospective study included 57 HD patients who had undergone SAVR-BP for AS between July 2009 and December 2020. Multivariate logistic regression was used to predict factors associated with mid-term outcomes and death or survival. Kaplan - Meier curves were also generated for mid-term survival. Results: The in-hospital mortality rate was 8.8%, and the 5-year mortality rate was 42.1%. The independent predictors of 5-year mortality were preoperative age (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.175-2.083, p = 0.002), hyperlipidemia (HR, 0.02; 95% CI, 0.002-0.297, p = 0.004), left ventricular diastolic diameter (HR, 1.74; 95% CI, 1.142-2.649, p = 0.010), left ventricular systolic diameter (HR, 0.61; 95% CI, 0.392-0.939, p = 0.025), and Japan SCORE (HR, 1.28; 95% CI, 1.052-1.563, p = 0.014). The postoperative predictors included intensive care unit stay (HR, 1.11; 95% CI, 1.035-1.194, p = 0.004) and albumin level (HR, 0.38; 95% CI, 0.196-0.725, p = 0.003). Conclusions: The 5-year prognosis of HD patients undergoing SAVR may be improved by early diagnosis (before the occurrence of LV hypertrophy/enlargement) and nutritional management with oral intake to alleviate postoperative hypoalbuminemia.Registration number of clinical studies: UMIN000047410.

Preoperative Serum GDF-15, Endothelin-1 Levels, and Intraoperative Factors as Short-Term Operative Risks for Patients Undergoing Cardiovascular Surgery.

OBJECTIVES: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. We investigated the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. METHODS: In total, 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by ELISA. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. RESULTS: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels; perioperative data (urine output); ICU stay period; and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. In multivariable logistic regression analysis, the preoperative ET-1 level and CPB time were the independent determinants of AKI, even adjusted by age, sex, and BMI. The preoperative GDF-15 level, CPB time, and RCC transfusion were independent determinants of 30-day mortality plus morbidity. CONCLUSION: Preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risks for patients undergoing cardiovascular surgery.

Lung-diffusing capacity for carbon monoxide predicts early complications after cardiac surgery.

PURPOSE: Preoperative pulmonary dysfunction has been associated with increased operative mortality and morbidity after cardiac surgery. This study aimed to determine whether values for the diffusing capacity of the lung for carbon monoxide (DLCO) could predict postoperative complications after cardiac surgery. METHODS: This study included 408 consecutive patients who underwent cardiac surgery between June 2008 and December 2015. DLCO was routinely determined in all patients. A reduced DLCO was clinically defined as %DLCO < 70%. %DLCO was calculated as DLCO divided by the predicted DLCO. The association between %DLCO and in-hospital mortality was assessed, and independent predictors of complications were identified by a logistic regression analysis. RESULTS: Among the 408 patients, 338 and 70 had %DLCO values of ≥ 70% and < 70%, respectively. Complications were associated with in-hospital mortality (P < 0.001), but not %DLCO (P = 0.275). A multivariate logistic regression analysis with propensity score matching identified reduced DLCO as an independent predictor of complications (OR, 3.270; 95%CI, 1.356-7.882; P = 0.008). CONCLUSIONS: %DLCO is a powerful predictor of postoperative complications. The preoperative DLCO values might provide information that can be used to accurately predict the prognosis after cardiac surgery. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000029985.

Association of serum concentrations of irisin and the adipokines adiponectin and leptin with epicardial fat in cardiovascular surgery patients.

Epicardial fat located adjacent to the heart and coronary arteries is associated with increased cardiovascular risk. Irisin is a myokine produced by skeletal muscle after physical exercise, and originally described as a molecule able to promote the browning of white adipose tissue and energy expenditure. In order to decrease cardiovascular risk, it has been proposed as a promising therapeutic target in obesity and type 2 diabetes. We investigated the relationships between serum concentrations of irisin and the adipokines adiponectin and leptin and body fat including epicardial fat in patients undergoing cardiovascular surgery. We obtained serum samples from 93 patients undergoing cardiovascular surgery (age 69.6 (SD 12.8) years, BMI 24.1 ± 4.8 kg/m2). Computed tomography (CT) and echocardiographic data were obtained from the routine preoperative examination. Subcutaneous fat area (SFA, cm2) and visceral fat area (VFA, cm2) near the umbilicus were automatically measured using the standard fat attenuation range. Epicardial fat area (EFA, cm2) was measured at the position where the heart became a long axis image with respect to the apex of the heart in the coronal section image. Total body fat mass, body fat percentage, and skeletal muscle volume (SMV) were estimated using bioelectrical impedance analysis (BIA). Serum irisin concentration was measured by enzyme-linked immunosorbent assay, and compared with adiponectin and leptin concentrations. The data were also compared with the clinical biochemical data. EFA was strongly correlated with BMI (P = 0.0001), non-HDL-C (P = 0.029), TG (P = 0.004), body fat mass (P = 0.0001), and body fat percentage (P = 0.0001). Serum leptin concentration showed a significant positive correlation with BMI (P = 0.0001) and TG (P = 0.001). Adiponectin, but not irisin, showed a significant negative correlation with BMI (P = 0.006) and TG (P = 0.001). Serum leptin level had a significant positive correlation with EFA, VFA, and SFA. In contrast, the serum adiponectin level was significantly negatively correlated with EFA, VFA, and SFA. The serum irisin level was also negatively correlated with EFA (r = -0.249, P = 0.015), and SFA (r = -0.223, P = 0.039), and tended to correlate with VFA (r = -0.198, P = 0.067). The serum level of adiponectin was negatively correlated with that of leptin (r = -0.296, P = 0.012), but there were no significant correlations between irisin and either adiponectin or leptin. Multivariate linear regression demonstrated that EFA showed a positive association with serum leptin level (ß = 0.438, P = 0.0001) and a negative correlation with serum irisin level (ß = -0.204, P = 0.038) and serum adiponectin level (ß = -0.260, P = 0.015) after adjusting for age, sex, and BMI. The present study provided the first evidence of associations of the serum irisin and adipokines (adiponectin and leptin) concentrations with epicardial fat in cardiovascular surgery patients. Irisin may play a role in preventing excess adiposity including epicardial fat, and consequently cardiovascular risk in patients.

Serum adiponectin and TNFα concentrations are closely associated with epicardial adipose tissue fatty acid profiles in patients undergoing cardiovascular surgery.

BACKGROUND: Epicardial adipose tissue (EAT) releases both adiponectin and TNFα, and these two adipokines play important roles in heart diseases such as coronary arterial disease. The aim of the present study was to clarify whether fatty acid (FA) profiles in EAT are linked to the serum concentration of these adipokines. The relationships between serum adipokine levels and FA profiles in patients undergoing cardiovascular surgery were analyzed. METHODS: Patients (n = 21) undergoing cardiovascular surgery (11 males, 70.4 ± 9.0 years, BMI 26.0 ± 5.1 kg/m2) were included. EAT samples were taken. We measured clinical biochemical data and FA profiles in venous blood and EAT samples using gas chromatography. Serum adiponectin and TNFα concentrations were also measured. RESULTS: The adiponectin and TNFα levels were not correlated with any fatty acid concentration in serum lipids. In contrast, there was a positive correlation between the serum adiponectin level and epicardial level of nervonic acid (C24:1ω9, r = 0.525, P = 0.025). In multiple regression analysis, adiponectin showed a positive association with the epicardial C24:1ω9 concentration after controlling for age and BMI, or TG, non-HDL-C, and BNP. The serum TNFα concentration was negatively correlated with the epicardial C18:3ω3, C12:0 and C18:0 content. In multiple regression analysis, the serum TNFα concentration showed a positive association with the epicardial C18:3ω3 level (ß = - 0.575, P = 0.015). CONCLUSIONS: These results suggest that there is a close relationship between epicardial FA profiles and serum levels of adiponectin and TNFα. Dietary therapy to target FA profiles may be helpful to modulate inflammation.

Severe hemolytic anemia caused by the NIPRO extracorporeal left ventricular assist device.

A 56-year-old woman with dilated cardiomyopathy underwent mitral and tricuspid annuloplasty, and simultaneous deployment of an extracorporeal left ventricular assist device (LVAD). Subsequently, she developed hemolytic anemia. Although the LVAD system was repeatedly exchanged and the mitral annular ring was removed, her hemolytic anemia did not improve. Finally, the NIPRO LVAD was replaced with Gyro Pump®, and her anemia was ameliorated. It appears important to consider the possibility of hemolytic anemia as a LVAD-related complication, although it would be rare.

Effects of continuous infusion of low-dose human atrial natriuretic peptide (hANP) on the lungs during cardiac surgery.

OBJECTIVE: The objective of this study was to determine the effects of a continuous infusion of low-dose hANP on the lungs during cardiac surgery in patients under cardiopulmonary bypass (CPB). METHODS: We analyzed 30 consecutive cases of cardiac surgery performed at our hospital from 2007-2008. The patients were divided into a group that received hANP (hANP group) or a group that received saline and no hANP (N-hANP group). We measured various parameters before and after surgery using a PiCCO monitor. RESULT: There were no differences in the preoperative characteristics between the groups, although urine volume during the operation was significantly greater in the hANP group. After surgery, there were no significant differences between the groups in cardiac output index (CI), global enddiastolic volume index (GEDVI), intrathoracic blood volume index (ITBI), pulmonary blood volume index (PBI), extravascular lung water index (ELWI) and pulmonary vascular permeability index (PVPI), total protein, and creatine. In contrast, interleukin-6 (IL-6) and renin were significantly lower, and albumin was significantly higher in the hANP group. CONCLUSION: We found that low-dose hANP during open cardiac surgery inhibited the secretion and plasma activity of IL-6 and renin. Although there were no differences in lung circulatory parameters such as the amount of fluid in the pulmonary blood vessels between the two groups, we believe that the strong diuretic effect of hANP reduced third-space fluid retention caused by CPB.

[Stanford type a acute aortic dissection with pectus excavatum].

Pectus excavatum is generally an isolated abnormality of the chest wall. However, some patients have a concomitant pectus deformity and cardiac & aortic disease. Decisions must be made regarding the operative approach and whether the pectus excavatum should be corrected during the same session. We report 2 patients with acute Stanford type A aortic dissection and pectus excavatum who underwent emergency operation. In case 1, median sternotomy is an unsuitable approach for open heart surgery, since the heart and great vessels are displace into the left hemithorax. But combined sternotomy and left anterior thoracotomy provided excellent surgical exposure. In case 2, we proceeded with a leftsided costotomy of four ribs and place a normal chest retractor providing as excellent exposure as combined sternotomy and left anterior thoracotomy. A left-sided costotomy of four ribs can be performed safely, eliminating the risks of median sternotomy in acute stanford type A aortic dissection with pectus excavatum.

Greater expression of inflammatory cytokines, adrenomedullin, and natriuretic peptide receptor-C in epicardial adipose tissue in coronary artery disease.

BACKGROUND: Growing evidence suggests that the epicardial adipose tissue may have local interactions with coronary arteries. In addition, vasoactive peptides such as adrenomedullin and natriuretic peptide has an interaction with adipose tissue. In this study, we investigated the relationship between adipokines, adipocytokines, and vasoactive peptides expressed in epicardial adipose tissue and subcutaneous adipose tissue in patients with and without coronary artery disease (CAD). METHODS: We studied 20 patients with CAD and 14 patients without CAD. We obtained blood samples and epicardial and subcutaneous adipose tissue at open-heart surgery. We measured serum cytokine levels and used real-time polymerase chain reaction (PCR) to measure mRNA levels of various molecules in epicardial and subcutaneous tissue and investigated the relation between mRNA levels and clinical parameters. RESULTS: The mRNA levels of IL-6, IL-1beta, MCP-1, and TNF-alpha were significantly higher in epicardial adipose tissue than in subcutaneous adipose tissue. Interestingly, the mRNA levels of IL-6, IL-1beta, MCP-1, natriuretic peptide receptor-C (NPR-C), adrenomedullin, and leptin in epicardial adipose tissue were higher in patients with CAD than those without CAD. In contrast, mRNA levels of adiponectin, PPAR-gamma, and NPR-A were similar in the two groups. In subcutaneous tissue, mRNA expressions of IL-6, IL-1beta, MCP-1, NPR-C, adrenomedullin, and leptin were modestly higher in patients with CAD than in those without CAD. There were no differences in plasma cytokine levels between the two groups. CONCLUSION: The mRNA levels of inflammatory cytokines, adipokines, neurohumoral factors and their receptors appear to be increased in epicardial adipose tissue independent of plasma levels of these molecules. Further studies are necessary to elucidate the pathophysiological role of these molecules in CAD.

Off-pump quintuple coronary artery bypass grafting for situs inversus totalis.

Dextrocardia associated with situs inversus totalis is a rare condition. A 49-year-old man with dextrocardia and situs inversus totalis underwent off-pump quintuple coronary artery bypass grafting using bilateral internal thoracic arteries and bilateral radial arteries. The operative technique was similar to that of off-pump coronary artery bypass grafting for situs solitus. His postoperative recovery was uneventful.

Aortopulmonary fistula due to perforation of the aortic wall of a freestyle stentless valve.

Aortopulmonary fistula occurring as a result of a rupture of the aortic wall of a stentless valve has not been previously reported. A 71-year-old woman suffered aortopulmonary fistula 15 months after replacement of the aortic root with a Freestyle stentless valve (Medtronic, Inc, Minneapolis, MN) and Dacron graft extension to replace the aortic valve and the ascending aorta to the aortic arch. We describe the successful repair of the fistula and simultaneous mitral valve replacement. The cause of deterioration of the aortic wall of the stentless valve, which gradually developed and ruptured, may have been primarily structural injury at the previous operation, with additional insult from the surgical adhesive used.

[Surgical repair of a large isolated internal iliac artery aneurysm presenting with acute renal failure. A case report].

A 71-year-old man was suffering from a large right internal iliac artery aneurysm (rt. IIAA) associated with acute renal failure secondary to bilateral hydronephrosis. Immediately after admission, we performed resection of the rt. IIAA and right common iliac artery-external iliac artery bypass. Postoperative recovery was uneventful and renal function improved. We should consider that a large isolated IIAA may uncommonly cause acute renal failure secondary to hydronephrosis. Expeditious surgical intervention may provide a complete recovery from acute renal failure.