Impact of New-Onset Right Bundle-Branch Block After Transcatheter Aortic Valve Replacement on Permanent Pacemaker Implantation.

BACKGROUND: A delayed and recurrent complete atrioventricular block (CAVB) is a life-threatening complication of transcatheter aortic valve replacement (TAVR). Post-TAVR evaluation may be important in predicting delayed and recurrent CAVB requiring permanent pacemaker implantation (PPI). The impact of new-onset right bundle-branch block (RBBB) after TAVR on PPI remains unknown. METHODS AND RESULTS: In total, 407 patients with aortic stenosis who underwent TAVR were included in this analysis. Intraprocedural CAVB was defined as CAVB that occurred during TAVR. A 12-lead ECG was evaluated at baseline, immediately after TAVR, on postoperative days 1 and 5, and according to the need to identify new-onset bundle-branch block (BBB) and CAVB after TAVR. Forty patients (9.8%) required PPI, 17 patients (4.2%) had persistent intraprocedural CAVB, and 23 (5.7%) had delayed or recurrent CAVB after TAVR. The rates of no new-onset BBB, new-onset left BBB, and new-onset RBBB were 65.1%, 26.8%, and 4.7%, respectively. Compared with patients without new-onset BBB and those with new-onset left BBB, the rate of PPI was higher in patients with new-onset RBBB (3.4% versus 5.6% versus 44.4%, P<0.0001). On post-TAVR evaluation in patients without persistent intraprocedural CAVB, the multivariate logistic regression analysis showed that new-onset RBBB was a statistically significant predictor of PPI compared with no new-onset BBB (odds ratio [OR], 18.0 [95% CI, 5.94-54.4]) in addition to the use of a self-expanding valve (OR, 2.97 [95% CI, 1.09-8.10]). CONCLUSIONS: Patients with new-onset RBBB after TAVR are at high risk for PPI.

Ratio of left ventricular outflow tract area to aortic annulus area and complete atrioventricular block after transcatheter aortic valve replacement for aortic stenosis.

BACKGROUND: Mechanical compression of cardiac conduction system by transcatheter heart valves leads to complete atrioventricular block (CAVB) after transcatheter aortic valve replacement (TAVR). Bulging of ventricular septum in the left ventricular outflow tract (LVOT) may be associated with greater compression of conduction system, leading to irreversible CAVB. OBJECTIVE: This study aimed to investigate the association of ventricular septal bulging with TAVR-related CAVB and permanent pacemaker implantation (PPI). METHODS: Among 294 consecutive patients with severe aortic stenosis who underwent TAVR between July 2017 and February 2023, 271 were included in the analysis. As a quantitative evaluation of bulging of the ventricular septum, the ratio of LVOT area to aortic annulus area (L/A ratio) was measured at the systolic phase of computed tomography images. RESULTS: TAVR-related CAVB occurred in 64 patients (23.6%). Twenty-eight patients (10.3%) required PPI. The optimal thresholds of L/A ratio for predicting TAVR-related CAVB and PPI were 1.0181 and 0.985, respectively. Patients with less than the cut-off values had higher rate of TAVR-related CAVB and PPI than those above (28.3% vs 13.1%, p = 0.0063; 14.7% vs 4.4%, p = 0.0077, respectively). A multivariate analysis showed that L/A ratio < 1.0181 was an independent predictor of TAVR-related CAVB (odds ratio [OR] 2.65, p = 0.011), in addition to prior right bundle branch block (OR 3.76, p = 0.0005), use of a self-expanding valve (OR 1.99, p = 0.030), and short membranous septum length (OR 0.96, p = 0.037). Only L/A ratio < 0.985 was independently associated with PPI (OR 3.70, p = 0.011). CONCLUSION: Low L/A ratio is a predictor of TAVR-related CAVB and PPI.

Clinical Usefulness of Echocardiographic Measurement of Proximal Aortic Diameter in Early Differentiation Between Type A Acute Aortic Dissection and ST-Segment-Elevation Myocardial Infarction.

Background Contradictions between management modalities of type A acute aortic dissection (TAAAD) and ST-elevation-myocardial infarction (STEMI) may result in clinical catastrophe. Therefore, we aimed to explore which 2-dimensional echocardiography (2DE) findings are optimal for differentiating TAAAD from STEMI. Methods and Results This study included 340 patients with STEMI and 340 patients with TAAAD who underwent 2DE in the emergency department between 2012 and 2021. The proximal ascending aorta (PAA) diameter and other echocardiographic parameters were analyzed. PAA diameters were measured at 4 levels in the parasternal view: Valsalva, the sinotubular junction (STJ), the PAA at 1 cm above the STJ, and the PAA at 2 cm above the STJ. Receiver-operating characteristic curve analysis showed that Valsalva, STJ, PAA at 1 cm above the STJ, and PAA at 2 cm above the STJ were significant predictors of TAAAD (areas under the curve: 0.777, 0.924, 0.965, and 0.975, respectively; P<0.001) with the respective cutoff values of 39.4, 38.5, 39.8, and 41.2 mm. Multivariable analysis suggested that all 2DE parameters were significant predictors of TAAAD. Among the 2DE parameters examined, the incorporation of PAA at 2 cm above the STJ to clinical indicators exhibited the most significant diagnostic capability (C-statistics, 0.97; net reclassification improvement, 1.81; integrated discrimination improvement, 0.61). When only TAAAD with coronary malperfusion and STEMI were analyzed, the diagnostic utility of PAA at 1 cm above the STJ was evident (C-statistics, 0.99; net reclassification improvement, 1.79; integrated discrimination improvement, 0.67), with PAA at 2 cm above the STJ ranking second in diagnostic significance (C-statistics, 0.99; net reclassification improvement, 1.12; integrated discrimination improvement, 0.66). Conclusions PAA measurements were the most beneficial for diagnosing TAAAD in all 2DE findings and TAAAD from STEMI.

Entry Site Is Associated With Aortic Enlargement After Pre-emptive Endovascular Repair for Uncomplicated Type B Aortic Dissection.

OBJECTIVES: We aimed to examine the mid-term results corresponding to the entry site in patients who underwent pre-emptive thoracic endovascular aortic aneurysm repair (TEVAR) for uncomplicated type B aortic dissection (TBAD). METHODS: We included 27 patients who underwent pre-emptive TEVAR for uncomplicated TBAD between September 2014 and December 2019. We divided the patients into 2 groups depending on the proximal landing zone (zone 2 group, zone ≥3 group) and retrospectively analyzed the risk of all-cause and aorta-related mortality, aortic events (rupture, open conversion, and secondary intervention), and aortic enlargement (≥5 mm). RESULTS: The median age of the patients was 53 (47-65) years. The median duration from the onset of uncomplicated TBAD to TEVAR was 43 (30-99) days, and the median follow-up duration was 48 (36-57) months. The maximum preoperative diameter of the dissected aorta was 40 mm in the zone 2 group and 35 mm in the zone ≥3 group (p=0.134). There was no case of hospital death or spinal cord ischemia; however, there was 1 (3.7%) case of perioperative stroke in the zone 2 group. Multivariate analysis of the risk factors for aortic enlargement following pre-emptive TEVAR for uncomplicated TBAD revealed that only zone 2 landing was an independent risk factor. The estimated Kaplan-Meier curve showed a higher rate of aortic enlargement in the zone 2 group at 4 years after pre-emptive TEVAR (46.4% vs 0%, log-rank test; p=0.011). CONCLUSIONS: In this study on TBAD, we found that zone 2 landing was associated with aortic enlargement after pre-emptive TEVAR. In cases where the distance from the left subclavian artery to a major entry point was short, there were more cases of aortic dilatation. CLINICAL IMPACT: The effectiveness of entry closure for type B aortic dissection was demonstrated in the INSTEAD XL trial. The cause of aortic enlargement after pre-emptive endovascular treatment for type B aortic dissection remains controversial. In the present study, zone 2 landing was a risk factor for aortic enlargement after pre-emptive thoracic endovascular aortic aneurysm repair (TEVAR) for uncomplicated type B dissection. Patients with zone 2 landing should be closely followed up after pre-emptive TEVAR.

Rapid anticalcification treatment for glutaraldehyde-fixed autologous tissue in cardiovascular surgery.

BACKGROUND: Glutaraldehyde (GA)-fixed autologous tissues, including the pericardium, are widely used as patches and valve substitutes in cardiovascular surgery. However, GA treatment causes tissue calcification. No rapid anticalcification method has been established for use during surgery. Here, we aimed to establish a rapid anticalcification method using ethanol, as has already been demonstrated for bioprosthetic valves. METHODS: Thoracic aorta tissues were first fixed with GA for 3 min and then treated with ethanol for 0 (group 2), 10 (group 3), 20 (group 4), and 30 (group 5) min; untreated tissues (group 1) served as the control. The treated tissues were subdermally implanted into 3-week-old male Wistar rats and kept in place for 28 days. The calcification in each explant was semiquantitatively evaluated by annotating and measuring the area using virtual slides, and the data obtained were statistically analyzed. RESULTS: Semiquantitative analysis revealed that calcification of the implants from the untreated group (group 1; P = 0.0014) and groups 4 (P = 0.0014) and 5 (P = 0.0031) was significantly lower than that of implants from group 2. Moreover, implants from group 3 showed a tendency toward decreased calcification, although it was not significant (P = 0.0503). CONCLUSIONS: A rapid ethanol treatment prevents calcification of GA-fixed tissues in a rat model of subdermal implantation. This method may facilitate effective and rapid anticalcification of autologous tissues for use during cardiovascular surgery.

Proposal of a new classification: "sealed type" postinfarction left ventricular free wall rupture.

OBJECTIVE: Postinfarction left ventricular free wall rupture (FWR) has been classified into blow-out type and oozing type. However, considering past papers, oozing type included the cases in which the bleeding had spontaneously stopped or sealed, and the distinction between blow-out type and oozing type was not always clear. We classified FWR into the BO type (combination of blow-out type and oozing type) with continuous bleeding and sealed type and clarified the pathophysiology of the sealed type. METHODS: Thirty-five patients who underwent surgical treatment for FWR during the past 21 years were retrospectively evaluated. RESULTS: Twenty-one patients (60%) were sealed. Comparing the sealed type with the BO type, the incidence of sudden collapse with acute onset was significantly lower (sealed type; 62%, BO type; 100%, P = 0.0118), and there were more cases of transport from outside the hospital (76%, 43%, P = 0.0453). Significantly few cases had electro-mechanical dissociation immediately before surgery (10%, 71%, P = 0.0001). In the sealed type, median sternotomy was performed in 9 patients (43%), and subxiphoid drainage was performed in 12 (57%). Fifteen patients (71%) were supported by IABP postoperatively, and re-rupture occurred in 3 patients without IABP. Long-term outcomes were significantly better in the sealed type than in the BO type. CONCLUSION: Sixty percent of postinfarction ventricular free wall rupture was the sealed type. Median sternotomy and sutureless repair with postoperative IABP support were reliable treatments. Subxiphoid drainage and strict blood pressure control with IABP may be acceptable surgical strategies in elderly, frail patients.

A massive postoperative stroke caused by a carotid thrombus that occurred during the surgical repair of an aortic dissection.

A 59-year-old man with no prior neurological deficits developed a massive stroke during the repair of a double-barreled acute type A aortic dissection with major entry in the ascending aorta and an occluded brachiocephalic artery. As right cerebral ischemia was alleviated by the circle of Willis, the patient was alert and conscious preoperatively. Nevertheless, the thrombus in the right carotid artery induced a severe postoperative right cerebral embolism. In conclusion, occlusion of the carotid artery is a risk factor of postoperative severe stroke, even in patients without neurological symptoms preoperatively.

Early coronary reperfusion using only guidewires for acute type A aortic dissection.

Coronary malperfusion with acute type A aortic dissection is a fatal complication. It is controversial whether to prioritize central repair or coronary reperfusion. Lifesaving becomes even more difficult if a patient has pericardial haemorrhage. Herein, we report a case of acute type A aortic dissection associated with left coronary malperfusion and pericardial haemorrhage, wherein reperfusion of the left coronary artery was performed using only guidewires, and central repair could be performed without major delay. Coronary reperfusion using only guidewires can be a revolutionary therapeutic strategy for this disease.

Brachiocephalic artery dissection is a marker of stroke after acute type A aortic dissection repair.

OBJECTIVE: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89; 95% confidence interval, 1.104-13.780; p = .035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION: BCA dissection was an independent risk factor of stroke after ATAAD repair.

Implementation of a beating heart system for training in off-pump and minimally invasive coronary artery bypass.

BACKGROUND: Several training devices have been developed to train anastomotic skills in off-pump coronary artery bypass grafting (OPCAB). However, assessment of trainees' improvement remains challenging. The goal of this study was to develop a new practical scoring chart and investigate its reliability and utility for anastomotic skills in OPCAB and minimally invasive direct coronary artery bypass (MIDCAB). METHODS: A training device was used, which included a beating heart model installed in a dedicated box. A soft plastic tube was used as the left anterior descending artery, and a porcine ureter was used as the left internal mammary artery. Five cardiac surgery fellows (Fellows, > 5 year of surgical experience) and five residents or medical students (Residents, ≤ 5 year of surgical experience) were enrolled for this study. Before and after training, skills were evaluated using a scoring chart that took into account anastomotic time, leakage, shape, flow measurement, and self-estimation. RESULTS: Mean total score of all trainees was 15.4 ± 4.0 at pre-training and 18.5 ± 2.4 at post-training (P = 0.05). Before training, there was a significant difference in the total score between Fellows and Residents (18.6 ± 2.2 vs 12.2 ± 2.4 points, P = 0.002), which disappeared after training (19.4 ± 2.5 vs 17.6 ± 2.2 points, P = 0.262). Residents benefitted from training with improvements in their time, total score, score for time, score for flow and subtraction score; however, these effects were not seen in Fellows. The most evident training effect was improvement of self-estimation, which was also seen in Fellows. CONCLUSIONS: Residents were most likely to derive benefit from these training models with regard to both efficiency and quality. Training models seem to have an important role in making surgeons feel more comfortable with the procedure.

Results of ascending aortic and arch replacement for type A aortic dissection.

OBJECTIVE: The outcomes of emergency surgery for type A acute aortic dissection have improved. However, ascending aortic replacement sometimes leads to dilatation of the distal aorta. The present study reviewed our outcomes of ascending aortic replacement and total arch replacement in patients with type A acute aortic dissection. METHODS: A total of 253 patients with type A acute aortic dissection underwent a central repair operation. Our standard technique was ascending aortic replacement. Total arch replacement was performed only when entry existed in the major curvature of the aortic arch and the proximal descending aorta. A total of 169 patients (67%) underwent ascending aortic replacement, and 84 patients (33%) underwent total arch replacement. Hospital death due to initial surgery, dilatation of the distal aorta greater than 5 cm, new occurrence of aortic dissection, any distal aortic surgery, and aortic-related deaths were defined as distal aortic events. RESULTS: The mortality was 7.1% in the ascending aortic replacement group and 6.0% in the total arch replacement group. Postoperative computed tomography was performed in 162 patients in the ascending aortic replacement group. The false lumen of the residual aortic arch had thrombosed and healed in 94 patients (58%) and remained present in 68 patients (42%). The distal aortic event-free rate in the ascending aortic replacement group decreased from 74% at 5 years to 51% at 9 years, and the rate in the total arch replacement group was 83% at 5 to 9 years (P < .01). For the ascending aortic replacement group, more patients with a dissected arch had a distal aortic event compared with patients with a healed arch (P < .01). CONCLUSIONS: Total arch replacement was associated with fewer distal aortic events. We may expand the indications for total arch replacement in stable patients.

Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation in descending aortic surgery.

Hypoxia during one-lung ventilation is a significant problem in descending aortic surgery via left thoracotomy. Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation (VAPa-ECMO), which consists of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and an additional arterial branch to perfuse a pulmonary artery (Pa), is useful.

Comparison of Hemodynamic Support by Impella vs. Peripheral Extra-Corporeal Membrane Oxygenation: A Porcine Model of Acute Myocardial Infarction.

Objectives: Several mechanical circulatory assist devices are used to treat critically ill patients requiring hemodynamic support during post-myocardial infarction or cardiogenic shock. However, little guidance is available to choose an appropriate device to match a particular patient's needs. An increased understanding of hemodynamic effects of the pump systems and their impact on myocardial pre-/afterload might help to better understand their behavior in different clinical settings. Methods: This was an open-labeled, randomized acute animal experiment. A model of acute univentricular myocardial injury by temporary balloon occlusion was used. The experiment was carried out in 10 juveniles female Piétrain pigs. The animals were randomized to mechanical hemodynamic support either by peripheral veno-arterial (VA-)ECMO or Impella CP. Results: While both devices were able to provide flows above 3 L/min and maintain sufficient end-organ perfusion, support by Impella resulted in a significantly more pronounced immediate effect on myocardial unloading: At the onset of device support, the remaining native cardiac output was reduced by 23.5 ± 15.3% ECMO vs. 66.2 ± 36.2% (Impella, p = 0.021). Native stroke volume was significantly decreased by Impella support compared to ECMO, indicating less mechanical work being conducted by the Impella-supported hearts despite similar total assisted cardiac output. Conclusions: Peripheral VA-ECMO and the transaortic Impella pump resulted in contrasting hemodynamic fingerprints. Both devices provided sufficient hemodynamic support and reduce left ventricular end-diastolic pressure in the acute setting. Treatment with the Impella device resulted in a more effective volume unloading of the left ventricle. A significant reduction in myocardial oxygen consumption equivalent was achieved by both devices: The Impella device resulted in a left-shift of the pressure-volume loop and a decreased pressure-volume-area (PVA), while VA-ECMO increased PVA but decreased heart rate. These data highlight the importance of specifically targeting heart rate in the management of AMI patients on hemodynamic support.

Excessive EP4 Signaling in Smooth Muscle Cells Induces Abdominal Aortic Aneurysm by Amplifying Inflammation.

OBJECTIVE: Excessive prostaglandin E2 production is a hallmark of abdominal aortic aneurysm (AAA). Enhanced expression of prostaglandin E2 receptor EP4 (prostaglandin E receptor 4) in vascular smooth muscle cells (VSMCs) has been demonstrated in human AAAs. Although moderate expression of EP4 contributes to vascular homeostasis, the roles of excessive EP4 in vascular pathology remain uncertain. We aimed to investigate whether EP4 overexpression in VSMCs exacerbates AAAs. Approach and Results: We constructed mice with EP4 overexpressed selectively in VSMCs under an SM22α promoter (EP4-Tg). Most EP4-Tg mice died within 2 weeks of Ang II (angiotensin II) infusion due to AAA, while nontransgenic mice given Ang II displayed no overt phenotype. EP4-Tg developed much larger AAAs than nontransgenic mice after periaortic CaCl2 application. In contrast, EP4fl/+;SM22-Cre;ApoE-/- and EP4fl/+;SM22-Cre mice, which are EP4 heterozygous knockout in VSMCs, rarely exhibited AAA after Ang II or CaCl2 treatment, respectively. In Ang II-infused EP4-Tg aorta, Ly6Chi inflammatory monocyte/macrophage infiltration and MMP-9 (matrix metalloprotease-9) activation were enhanced. An unbiased analysis revealed that EP4 stimulation positively regulated the genes binding cytokine receptors in VSMCs, in which IL (interleukin)-6 was the most strongly upregulated. In VSMCs of EP4-Tg and human AAAs, EP4 stimulation caused marked IL-6 production via TAK1 (transforming growth factor-ß-activated kinase 1), NF-κB (nuclear factor-kappa B), JNK (c-Jun N-terminal kinase), and p38. Inhibition of IL-6 prevented Ang II-induced AAA formation in EP4-Tg. In addition, EP4 stimulation decreased elastin/collagen cross-linking protein LOX (lysyl oxidase) in both human and mouse VSMCs. CONCLUSIONS: Dysregulated EP4 overexpression in VSMCs promotes inflammatory monocyte/macrophage infiltration and attenuates elastin/collagen fiber formation, leading to AAA exacerbation.

Acute iliac arterial thrombosis during laparoscopic abdominoperineal resection.

BACKGROUND: Acute iliac arterial thrombosis during surgery is very rare complication. There were few reports on this complication relative to gastroenterological surgery, and the risk has not been recognized. CASE PRESENTATION: A 70-year-old man, diagnosed with a rectal cancer (adenocarcinoma of rectum) with known history heavy cigarette smoking with no known history of peripheral vascular disease underwent a laparoscopic abdominoperineal resection. He presented severe pain in the left leg in the recovery room. A computed tomography (CT) scan revealed the complete obstruction of the left common iliac artery. A successful revasculization was achieved through a thrombotectomy and percutaneous transluminal angioplasty with a stent immediately after the diagnosis. The pain in the left leg disappeared immediately after the revasculization. CONCLUSION: An acute arterial thrombosis is a potential complication of the laparoscopic colorectal surgery with the lithotomy position.

An appropriately sized soft polyester external stent prevents enlargement and neointimal hyperplasia of a saphenous vein graft in a canine model.

Although the efficacy of external stents for vein grafts in coronary artery bypass grafting has been recognized, the ideal diameter and material of the stent remain controversial. We created a new external stent made of soft polyester mesh and performed an animal experiment using canines. Bilateral saphenous vein grafts were interposed in the bilateral common carotid artery of 10 beagles. The grafts in the left carotid artery were designated as the control group, and those in the right rolled by a soft polyester mesh external stent were designated as mesh group. Two of the 10 animals were sacrificed due to severe wound infection. The other eight were observed by echography for 6 months, and then grafts were extracted and thickness of the neointima of the grafts was measured. The control group showed 146% ± 26% postoperative enlargement of the internal diameter of the vein grafts after 6 months, whereas the mesh group showed only 115% ± 15% after the same duration (P = 0.0003). The median thickness of the neointima in the mesh group (170 µm [range: 150-190]) was significantly thinner than that in the control group (260 µm [range: 220-310], P < 0.0001). Some degree of correlation between the thickness of neointima and proportion of enlargement was noted (r = 0.518, P = 0.0024). A soft polyester mesh external stent for vein grafts successfully suppressed the enlargement of the vein grafts and thickness of the neointima after 6 months.

A selective antagonist of prostaglandin E receptor subtype 4 attenuates abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is a progressive disease that has an increasing prevalence with aging, but no effective pharmacological therapy to attenuate AAA progression is currently available. We reported that the prostaglandin E receptor EP4 plays roles in AAA progression. Here, we show the effect of CJ-42794, a selective EP4 antagonist, on AAA using two mouse models (angiotensin II- and CaCl2 -induced AAAs) and human aortic smooth muscle cells isolated from AAA tissue. Oral administration of CJ-42794 (0.2 mg/kg per day) for 4 weeks significantly decreased AAA formation in ApoE-/- mice infused with angiotensin II (1 µg/kg per min), in which elastic fiber degradation and activations of matrix metalloproteinase (MMP)-2 and MMP-9 were attenuated. Interleukin-6 (IL-6) proteins were highly expressed in the medial layer of angiotensin II-induced mouse AAA tissues, whereas this expression was significantly decreased in mice treated with CJ-42794. AAA formation induced by periaortic CaCl2 application in wild-type mice was also reduced by oral administration of CJ-42794 for 4 weeks. After oral administration of CJ-42794 beginning 2 weeks after periaortic CaCl2 application and continuing for an additional 4 weeks, the aortic diameter and elastic fiber degradation grade were significantly smaller in CJ-42794-treated mice than in untreated mice. Additionally, in smooth muscle cells isolated from human AAA tissues, stimulation of CJ-42794 inhibited PGE2 -induced IL-6 secretion in a dose-dependent manner and decreased PGE2 -induced MMP-2 activity. These data suggest that inhibition of EP4 has the potential to be a pharmacological strategy for attenuation of AAA progression.

Treatment of coronary malperfusion in type A acute aortic dissection.

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient's condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.

Proteomic analysis of aortic smooth muscle cell secretions reveals an association of myosin heavy chain 11 with abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is a life-threatening disease, and no disease-specific circulating biomarkers for AAA screening are currently available. We have identified a smooth muscle cell (SMC)-specific biomarker for AAA. We cultured aneurysmal tunica media that were collected from eight patients undergoing elective open-repair surgeries. Secreted proteins in culture medium were subjected to liquid chromatography/tandem mass spectrometry. Myosin heavy chain 11 (myosin-11) was identified as a SMC-specific protein in the tunica media-derived secretions of all patients. We then examined myosin-11 protein concentrations by ELISA in plasma samples from patients with AAA ( n = 35) and age-matched healthy control subjects ( n = 34). Circulating myosin-11 levels were significantly higher in patients with AAA than control subjects. The area under the receiver-operating characteristic curve (AUC) of myosin-11 was 0.77, with a specificity of 65% at a sensitivity of 91%. Multivariate logistic regression analysis showed a significant association between the myosin-11 level and presence of AAA. When the myosin-11 level was combined with hypertension, it improved the prediction of AAA (AUC 0.88) more than hypertension per se. We then investigated the correlation between aortic diameter and circulating myosin-11 levels using AAA serum samples from patients undergoing endovascular aneurysm repair ( n = 20). Circulating myosin-11 levels were significantly correlated with maximum aortic diameter. Furthermore, changes in myosin-11 concentrations from the baseline 12 mo after endovascular aneurysm repair were associated with those in aortic diameter. These data suggest that circulating levels of myosin-11, which is a SMC-specific myosin isoform, may be useful as a biomarker for AAA. NEW & NOTEWORTHY Extensive studies have revealed that inflammation- or proteolysis-related proteins are proposed as biomarkers for abdominal aortic aneurysm (AAA). Changes in these protein concentrations are not specific for smooth muscle, which is a major part of AAA pathologies. Hence, no disease-specific circulating markers for AAA are currently available. We found, using secretome-based proteomic analysis on human AAA tunica media, that myosin heavy chain 11 was associated with AAA. Circulating myosin heavy chain 11 may be a new tissue-specific AAA marker.