Utility of growth differentiation factor-15 as a predictor of cardiovascular surgery outcomes: Current research and future directions.

In a world increasingly confronted by cardiovascular diseases (CVDs) and an aging population, accurate risk assessment prior to cardiac surgery is critical. Although effective, traditional risk calculators such as the Japan SCORE, Society of Thoracic Surgeons score, and EuroSCORE II may not completely capture contemporary risks, particularly due to emerging factors such as frailty and sarcopenia. These calculators often focus on regional and ethnic specificity and rely heavily on evaluations based on age and underlying diseases. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine that has been identified as a potential biomarker for sarcopenia and a tool for future cardiac risk assessment. Preoperative plasma GDF-15 levels have been associated with preoperative, intraoperative, and postoperative factors and short- and long-term mortality rates in patients undergoing cardiac surgery. Increased plasma GDF-15 levels have prognostic significance, having been correlated with the use of cardiopulmonary bypass during surgery, amount of bleeding, postoperative acute kidney injury, and intensive care unit stay duration. Notably, the inclusion of preoperative levels of GDF-15 in risk stratification models enhances their predictive value, especially when compared with those of the N-terminal prohormone of brain natriuretic peptide, which does not lead to reclassification. Thus, this review examines traditional risk assessments for cardiac surgery and the role of the novel biomarker GDF-15. This study acknowledges that the relationship between patient outcomes and elevated GDF-15 levels is not limited to CVDs or cardiac surgery but can be associated with variable diseases, including diabetes and cancer. Moreover, the normal range of GDF-15 is not well defined. Given its promise for improving patient care and outcomes in cardiovascular surgery, future research should explore the potential of GDF-15 as a biomarker for postoperative outcomes and target therapeutic intervention.

False lumen thrombus following aortic dissection diagnosed as the source of repeat lower extremity emboli with angioscopy: a case report.

BACKGROUND: Acute arterial embolization caused by a free-floating thrombus of the false lumen after surgery for acute aortic dissection is a rare complication; hence, determining its cause may be difficult. We report a case in which angioscopy was valuable in diagnosing and treating the unstable thrombus within the false lumen. CASE PRESENTATION: The patient was a 71-year-old woman who underwent hemiarch replacement for Stanford type A acute aortic dissection. Two months after the operation, left renal infarction occurred. Eighteen months after the operation, the patient visited the hospital for treatment of intermittent claudication of her left leg. Computed tomography (CT) showed occlusion below the left common femoral artery. Surgical thrombectomy was performed for acute lower extremity arterial occlusion. One month later, thrombectomy was performed again for the same phenomenon and again after 2 months. She had no history of cardiac arrhythmia. No obvious source for the repeat embolization could be found on echocardiography or enhanced CT. Angiography was performed to further identify the cause, revealing a new entry site at the distal anastomosis, which exhibited antegrade flow into the false lumen. Furthermore, selective false lumen angiography via the re-entry revealed a thrombus in the false lumen corresponding to the descending aorta. A non-obstructive angioscopy system in the false lumen revealed a free-floating thrombus. As the patient had undergone multiple surgeries over a short period and desired minimally invasive treatment, coil embolization of the new entry site as well as false lumen was performed. As a result, blood flow from the true to the false lumen resolved. More than 1 year has passed following coil embolization with no signs of embolism. CONCLUSIONS: We experienced a case of repeat embolism caused by unstable thrombus formation in the false lumen resulting from antegrade blood flow in the false lumen secondary to development of a new entry site. Angioscopy revealed that this antegrade flow caused formation of an unstable thrombus which caused recurrent acute lower extremity arterial occlusion. Therefore, angioscopy may be a useful option for the diagnosis of false lumen thrombosis.

Clinically feasible method for assessing leukocyte rheology in whole blood.

This study reports a novel method for assessment of leukocyte rheological activation with a new designed microchannel array chip to mimic the human microvascular network for microchannel array flow analysis (MCFAN). Study subjects were 79 healthy volunteers and 42 patients with type 2 diabetes mellitus (DM) and 36 patients with acute coronary syndrome (ACS). Using the anticoagulants heparin and ethylene-diamine-tetraacetic acid (EDTA)-2Na which inhibits platelets and leukocytes by chelating Ca2+, we were able to quantify leukocyte rheological activation by the subtraction of passage time of blood treated with both heparin and EDTA-2Na from that of blood treated with heparin only. We confirmed that passage times of whole blood with heparin + EDTA-2Na were always shorter than those of whole blood with only heparin in healthy subjects and patients with DM or ACS under suction pressures of - 30 cmH2O. There was a significant correlation between delta whole blood passage time {(heparin tube) - (EDTA-2Na + heparin)} and serum levels of myeloperoxidase and adhesive leukocyte number, respectively, even in blood from patients with DM or ACS, who suffered from inflammation. In conclusion we have developed a clinically feasible method for assessing leukocyte rheological activation in whole blood in ex vivo.

Right internal jugular vein thrombosis caused by aneurysm of right-sided aortic arch.

A right-sided aortic arch is normally asymptomatic. We report the case of an 84-year-old man with right internal jugular vein thrombosis caused by an aneurysm in a right-sided aortic arch. The patient had undergone open repair of an abdominal aortic aneurysm and had an uneventful postoperative course. However, a routine postoperative contrast-enhanced thoracic and abdominal computed tomography scan showed right internal jugular vein thrombosis. The patient had no history of catheter insertion in the right jugular veins and had no hereditary coagulopathy. It was presumed that the cause of this thrombosis was compression of the right brachiocephalic vein by an aneurysm of the right-sided ascending aorta that was considered too small to require surgical repair. The right internal jugular vein thrombosis was successfully treated with edoxaban. .

Ileosigmoid knot at week 13 of pregnancy: report of a case.

The ileosigmoid knot (ISK) is a rare cause of intestinal obstruction. ISK is a condition in which the ileum wraps around the base of the sigmoid colon and forms a knot, leading to high mortality with rapid progression to bowel gangrene. We herein report a rare case of ISK at week 13 of pregnancy. The ISK was diagnosed by computed tomography, and the patient underwent emergency surgery for acute abdomen. Laparotomy showed segmental gangrenous change in the sigmoid colon, which was twisted around the distal ileal loop. The gangrenous bowel was resected, and primary anastomosis was performed. To our knowledge, the present case involves the first and earliest pregnancy in which a preoperative diagnosis of ISK was made and successful treatment was performed with surgery. A radiologic approach should be undertaken for prompt diagnosis and optimal management, even in early pregnancy.

[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.

Oral vancomycin may have significant absorption in patients with Clostridium difficile colitis.

A patient on haemodialysis with bowel ischemia was given vancomycin 500 mg orally every 6 h for superimposed Clostridium difficile colitis resulting in a high vancomycin serum concentration. When treating C. difficile colitis in patients with significant renal impairment and bowel injury, we recommend administering the lower dose of oral vancomycin.