Efficacy and safety of remote cardiac rehabilitation in the recovery phase of cardiovascular diseases (RecRCR study): A multicenter, nonrandomized, and interventional trial in Japan.

Backgrounds: Remote cardiac rehabilitation has proven useful in patients with cardiovascular disease; however, the methodology had not been fully validated. This study aimed to investigate the efficacy and safety of remote cardiac rehabilitation (RCR) with real-time monitoring and an ergometer using a bidirectional communication tool during the recovery phase of cardiovascular diseases. Methods: This multicenter, nonrandomized, interventional study was conducted at 29 institutions across Japan and enrolled patients with cardiovascular diseases who met indications for cardiac rehabilitation (CR) after receiving in-hospital treatment. The RCR group exercised at home using an ergometer and was monitored in real-time using interactive video and monitoring tools for 2-3 months. Educational instructions were provided concurrently through e-learning approaches. The safety of the RCR protocol and the improvement in peak oxygen consumption (VO2) were compared with those of the historical control group that participated in center-based CR. Results: Fifty-three patients from the RCR group were compared with 103 historical controls having similar background characteristics. No patients in RCR experienced significant cardiovascular complications while engaging in exercise sessions. After 2-3 months of RCR, the peak VO2 improved significantly, and the increases in the RCR group did not exhibit any significant differences compared to those in the historical controls. During follow-up, the proportion of patients whose exercise capacity increased by 10% or more was also evaluated; this finding did not indicate a statistically significant distinction between the groups. Conclusions: RCR during the recovery phase of cardiovascular diseases proved equally efficient and safe as center-based CR.

[Resection of a Subclavian Artery Aneurysm without Dividing the Clavicle;Report of a Case].

A 57-year-old woman with Marfan syndrome had undergone the surgical treatment for pectus excavatum at 15 years of age. She had since been screened regularly by computed tomography(CT) to detect any vascular diseases. CT demonstrated a left subclavian arterial aneurysm at 55 years of age. It enlarged to a diameter of 32 mm, and surgical treatment was performed. The subclavian artery and the aneurysm were identified by echography in order to locate the exact sites of supraclavicular and subclavicular skin incisions. The subclavian artery aneurysm was resected without dividing the clavicle, and replaced by a vascular graft. Echography is useful for precisely locating a subclavian artery aneurysm, which enables feasible resection without dividing the clavicle.

Reconstruction of the right ventricular outflow tract after surgical removal of a cardiac hemangioma.

An asymptomatic 73-year-old man underwent resection of a cardiac tumor arising from the right ventricular outflow tract, and reconstruction of the right ventricular outflow tract using an expanded polytetrafluoroethylene sheet. Histological examination revealed a cavernous-capillary type cardiac hemangioma, which is a very rare cardiac tumor.

Floating thrombus originating from an almost normal thoracic aorta.

We present a case of floating thrombus originating from an almost normal thoracic aorta in a 54-year-old man who presented with acute arterial occlusion of his left leg. Transesophageal echocardiography (TEE), computed tomography, and magnetic resonance imaging showed two masses in an almost normal aorta after embolectomy for the acute arterial occlusion. Although the embolus was thrombus histologically, malignant tumors could not be ruled out. The masses did not decrease in size after 7 days of anticoagulant therapy, so they were extirpated under cardiopulmonary bypass (CPB) and TEE guidance. Frozen section examination during CPB indicated that there was no evidence of malignancy in the removed mass. TEE played an important role in the diagnosis and surgery of this condition, and it was useful when deciding on a surgical strategy. Because the treatment strategy for this disease remains controversial, further studies are needed.

A case of biatrial multiple myxomas with glandular structure.

A 45-year-old male, who had been indicated by brain magnetic resonance imaging to have cerebral infarctions, was found by echocardiography to have a tumor in the left atrium. He had experienced several of the constitutional disturbances associated with myxoma. At the ages of 19 and 35 he had had two episodes associated with embolisms, and at the later one he was diagnosed as having multiple cerebral aneurysms. He received an urgent operation in which three left atrial tumors and one right atrial tumor were resected. Histologically, the tumors were myxomas, and the left atrial main tumor had glandular structure. In view of his clinical history, this patient seems to have had cardiac myxomas for a long period. The multiple growths that occurred in this case may be a good argument for allowing this condition to last for so long. To our knowledge, the present case was the first report of cardiac myxoma with glandular structure in Japan.

A reduced priming system.

Cardiopulmonary bypass (CPB), an integral part of valve surgery, is known to cause hemodilution, which can lead to a need for blood transfusion as well as a systemic inflammatory reaction. Our aim was to evaluate a reduced priming (RP) system for CPB with regard to clinical outcomes in patients undergoing valve surgery. Eleven patients were assigned to the new system with an RP volume. The RP system allowed for reduced hemodilution and a possible reduction in the necessity for blood transfusions.

Deterioration of body oxygen metabolism by vasodilator and/or vasoconstrictor administration during cardiopulmonary bypass.

During cardiopulmonary bypass (CPB), tissue perfusion injury occurs even if perfusion pressure is maintained. Although a vasodilator and a vasoconstrictor are clinically administered if bypass flow is maintained, they may restore perfusion pressure without improving tissue perfusion. We evaluated the influence of vasodilators and vasoconstrictors on the whole body during CPB. Fifty-six patients with valvular disease who received moderately hypothermic CPB without blood transfusion were divided into four groups, depending upon whether a vasodilator and/or a vasoconstrictor was administered, and postoperative data were compared. Bypass flow and aortic pressure were maintained at 2.4 l/min/m and 5090 mm Hg. Body weight, dilution, hematocrit level, CPB, and aortic clamp duration, blood temperature, bypass flow, perfusion pressure, base excess levels during CPB, cardiac index, arterial and mixed venous oxygen pressure, and alveolar-arterial oxygen distribution after CPB were comparable among the four groups. However, the time to extubation was significantly longer. Blood lactate levels, measured for patients returned to the ward, were significantly higher in the agent-administered groups than in the no-agent group, whereas blood lactate levels on extubation and blood creatinine levels on postoperative day 1 were comparable among the groups. Vasodilator and/or vasoconstrictor administration during CPB may deteriorate the body oxygen metabolism, which might imply tissue perfusion and worsen the complications induced by hypoperfusion during CPB.

Vasoconstrictor administration during cardiopulmonary bypass affects acid-base balance in infants and children.

BACKGROUND: In experimental reports, blood flow redistribution occurred during cardiopulmonary bypass (CPB) and perfusion pressure was restored by vasoconstrictor administration without improving splanchnic perfusion. The influence of vasoconstrictor administration during CPB was clinically examined. MATERIALS AND METHODS: Twenty-two consecutive pediatric CPB cases of ventricular septal defect without blood transfusion were divided into two groups, depending upon whether a vasoconstrictor was administered during CPB or not (n = 7 vs. 15). Bypass flow and systemic perfusion pressure during CPB were maintained at 2.5 L/m(2)/min and not lower than 30 mm Hg by vasoconstrictor administration, respectively. RESULTS: Although preoperative state and CPB conditions were comparable between the two groups, more sodium bicarbonate was administered (P < 0.05); duration from the operation to extubation was longer (P < 0.05); and bowel movement occurred later in the vasoconstrictor-administered group than in the control group. CONCLUSIONS: Vasoconstrictor administration during CPB may deteriorate the acid-base balance and the postoperative state in infants and children.

A single-stage operation for abdominal aortic aneurysm with concomitant colorectal carcinoma.

The coexistence of abdominal aortic aneurysm (AAA) and colorectal carcinoma needs special operative consideration. A single-stage operation for concomitant AAA and colorectal carcinoma has been thought to increase the risk of vascular prosthetic graft infection. We report two patients who received a single-stage operation for AAA and colorectal carcinoma. The first patient had a fusiform aneurysm of the infrarenal aorta. The second patient had a saccular aneurysm of the infrarenal aorta and a fusiform aneurysm of the left internal iliac artery. Both patients had left-sided colorectal carcinoma classified as Dukes' stage B. The two patients underwent a single-stage operation with Hartmann's procedure to avoid graft infection caused by anastomotic leakage. They tolerated the operation and had no postoperative complications including graft infection. A single-stage operation for concomitant AAA and left-sided colorectal carcinoma could be safely performed with Hartmann's procedure in two cases.

Clinical application of bone marrow implantation in patients with arteriosclerosis obliterans, and the association between efficacy and the number of implanted bone marrow cells.

BACKGROUND: There have been a number of recent reports on the use of autologous bone marrow implantation (BMI) in the treatment of peripheral arterial disease, with a clinical response rate of approximately 70%. However, the factors that influence efficacy have not yet been clarified. We have analyzed the relationship between the number of implanted bone marrow cells and the clinical efficacy of BMI. METHODS AND RESULTS: Eight patients with arteriosclerosis obliterans were treated with BMI. Bone marrow was aspirated from the ilium (500-1,000 ml), the mononuclear cells were separated and then were implanted. The clinical effectiveness of BMI was evaluated by assessing changes in the ankle-brachial pressure index (ABI) and the transcutaneous oxygen pressure (TcO2) between the pre-treatment baseline, with follow-up testing at 4 weeks. These changes were defined as DeltaABI and DeltaTcO2. The mean number of CD34-positive cells was 1.04+/-0.60 x10(6) /kg body weight. There was a strong correlation between the number of CD34-positive cells and DeltaABI (r=0.754, p=0.028). CONCLUSIONS: It is likely that the number of implanted CD34-positive cells is one of the primary factors that influence the clinical efficacy of BMI.

Preoperative respiratory physiotherapy for a patient with severe respiratory dysfunction and annuloaortic ectasia.

A 23-year-old man with Marfan syndrome, who had undergone surgery for pectus excavatum and scoliosis and who had severe respiratory dysfunction, was referred for surgical repair of annuloaortic ectasia. The preoperative pulmonary function test revealed severe obstructive and restrictive respiratory dysfunction, with forced expiratory volume in one second of 650 ml and vital capacity of 1,220 ml. These parameters improved after 4 months respiratory physiotherapy. A modified Bentall's procedure was performed after respiratory physiotherapy. A tracheostomy made on the 7th postoperative day (POD) appeared to improve respiratory condition and he was weaned off mechanical ventilation on the 14th POD. The lower limits of pulmonary function for open heart surgery have not been established clearly; however, our case will help elucidate these limits of respiratory function for open heart surgery. Preoperative respiratory physiotherapy improved parameters of pulmonary function test and may decrease the morbidity of postoperative pulmonary complications in a patient with severe respiratory dysfunction.

Therapeutic role of pericardiocentesis for acute necrotizing eosinophilic myocarditis with cardiac tamponade.

We describe a patient with acute necrotizing eosinophilic myocarditis who recovered rapidly after pericardial drainage and without corticosteroid therapy. The 25-year- old man was referred to our hospital with suspected acute myocardial infarction on the basis of severe epigastralgia, abnormal Q waves and ST elevation on electrocardiography, and an increase in cardiac enzymes. Echocardiography disclosed pericardial effusion that compressed the right ventricle, left ventricular dysfunction in conjunction with posterolateral hypokinesis, and a thickened ventricular wall but no mural thrombus. The eosinophil count in the peripheral blood was slightly increased. Coronary angiography showed normal arteries and thus prompted an endomyocardial biopsy. The patient was transferred to the intensive care unit with a clinical diagnosis of myocarditis associated with cardiac tamponade. Emergency pericardiocentesis relieved symptoms immediately. The cells in the pericardial effusion were mainly eosinophils; interleukin 5 and interleukin 13 levels were predominantly elevated, and the effusion was drained for 5 days. The biopsy specimen revealed necrotizing eosinophilic myocarditis. Left ventricular function recovered within a week without corticosteroid therapy. No relapse was observed as of 8 months after diagnosis.