[Two-staged Operation for Bilateral Giant Bullae Successfully Performed with Veno-venous Extracorporeal Membrane Oxygenation( V-V ECMO) for First Surgery].

57-year-old man with bilateral giant lung bullae was admitted to our hospital for dyspnea on exertion as his chief complaint. The size and shape of right lung bullae were bigger and more complicated than those of left lung bullae. He underwent 2-staged bullectomy by video-assisted thoracoscopic surgery (VATS). Left lung bullectomy was expected to be more safely done, and was performed with veno-venous extracorporeal membrane oxygenation( V-V ECMO) prior to right side without any complications. The right lung bullectomy was performed 6 months after 1st operation without V-V ECMO. These reoperations were necessary due to postoperative air leak, however, his respiratory condition was well maintained by his left lung which had already been remarkably improved.

Clinical characteristics associated with pacing-induced cardiac dysfunction: a high incidence of undiagnosed cardiac sarcoidosis before permanent pacemaker implantation.

Previous studies suggested that right ventricular pacing was associated with pacing-induced cardiac dysfunction (PICD). The purpose of this study was to investigate the clinical characteristics including the incidence of undiagnosed cardiac sarcoidosis (CS) in patients with atrioventricular block (AVB) who manifest PICD. We retrospectively investigated consecutive patients with permanent pacemaker (PPM) undergoing a first-generator replacement surgery with a new PPM or an upgrade procedure to a cardiac resynchronization therapy (CRT) device between December 1, 2011 and June 30, 2017. Patients with AVB showing normal echocardiographic findings before PPM implantation were included and divided into 2 groups: patients with post-PPM left ventricular ejection fraction (LVEF) < 40% and/or undergoing an upgrade procedure to CRT (PICD group) and patients with post-PPM LVEF ≥ 40% who underwent replacement surgery with a new PPM (no-PICD group). There were 15 and 41 patients in the PICD and no-PICD groups, respectively. A wider-paced QRS duration just after the PPM implantation and/or lower pre-PPM LVEF was observed in the PICD group. Furthermore, 46.7% of the PICD patients (7/15) satisfied the diagnostic criteria for CS according to the guideline of the Japanese Circulation Society, although no patients fulfilled these criteria before PPM implantation. In conclusion, a high incidence of CS was observed in patients with AVB who had PICD. However, none of these patients was diagnosed with CS before PPM implantation.

Marshall bundle reentrant atrial tachycardia after the Cox-Maze IV procedure: The last barrier of the conduction pathway between the coronary sinus and left atrium.

A 74-year-old woman who developed atrial tachycardia following the Cox-Maze IV procedure underwent catheter ablation. The reentrant circuit included the coronary sinus (CS), Marshall bundle (MB), distal MB-left atrial (LA) connection, and anterolateral mitral annulus. The distal MB-LA connection was the last barrier in the conduction pathway between the CS and the left atrium.

Clinical background including anticoagulant therapy in patients with atrial fibrillation in a community-based survey: the Saitama AF Registry.

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, and carries an increased risk of cardiogenic embolism. Oral anticoagulants (OACs) including warfarin and/or non-vitamin K antagonists can prevent the majority of these events. The Saitama AF Registry was a community-based survey of patients with AF in Saitama City, which represents an urban community in Japan. A total of 75 institutions participated in the registry and attempted to enroll consecutive patients with AF from September 2014 to August 2015. The aim of the present study was to examine the clinical characteristics of patients with AF using data of the Saitama AF Registry. In addition, we investigated the difference in clinical characteristics of the patients between small-sized hospitals and large-sized hospitals. A total of 3591 patients were enrolled; 57.7% of all patients were enrolled from small-sized hospitals, whereas 42.3% were from large-sized hospitals. The patients from small-sized hospitals had higher CHADS2 score than those from large-sized hospitals. Approximately, 80% of all patients were treated with OACs, and the prescription rate was higher in patients with CHADS2 score ≥ 2 from both small-sized hospitals and large-sized hospitals. In conclusion, the present study demonstrated an appropriate use of OACs for high-risk patients with CHADS2 score ≥2 in Saitama City regardless of hospital size.

Peri-Mitral Atrial Tachycardia Using the Marshall Bundle Epicardial Connections.

OBJECTIVES: The aim of this study was to determine whether re-entrant circuits were associated with the ligament of Marshall (LOM). BACKGROUND: Peri-mitral atrial tachycardias (PMATs) following pulmonary vein isolation (PVI) or mitral valve surgery are common. METHODS: Six PMATs involving epicardial circuits were identified from 38 patients. Of these, 4 PMATs involved the LOM (PMAT-LOM, mean cycle length 308 ± 53 ms), as confirmed by the insertion of a 2-F electrode in the vein of Marshall (VOM). All patients underwent PVI and mitral isthmus ablation. The PMAT-LOMs were diagnosed based on left atrium (LA) activation maps that covered <90% of tachycardia cycle length (TCL), and a difference between the post-pacing interval and TCL that was: 1) ≤20 ms at the VOM, the ridge between the left pulmonary vein and appendage, the anterior wall of the LA, and along the 6 to 11 o'clock direction of the mitral annulus; and 2) >20 ms at the distal coronary sinus (CS), the posterior wall of the LA, and the mitral isthmus ablation line (or noncapture). Catheter ablation was performed at the ridge for all PMAT-LOMs. RESULTS: Three tachycardias were successfully terminated at the ridge, which showed continuous fractionated potential lasting >100 ms, confirming the bidirectional block of Marshall bundle (MB)-LA connections. The remaining tachycardia required ablation for the CS-MB connections, confirming bidirectional block of CS-MB connections. CONCLUSIONS: PMAT-LOMs following PVI or valve surgery accounted for up to 11% of PMATs. The bidirectional block of either MB-LA or CS-MB connections is required to eliminate PMAT-LOMs.

Pulmonary hypertension due to left heart disease: The prognostic implications of diastolic pulmonary vascular pressure gradient.

BACKGROUND: Compared to transpulmonary pressure gradient (TPPG), diastolic pulmonary vascular pressure gradient (DPG) may be a more sensitive and specific indicator for pulmonary hypertension (PH) due to left heart disease (LHD) with significant pulmonary vascular disease (PVD). The aim of this study was to investigate the incidence and clinical features of PH-LHD with PVD classified by DPG and TPPG. METHODS: We analyzed 410 patients admitted for symptomatic heart failure (HF) (New York Heart Association ≥2) and who underwent right heart catheterization (RHC) at compensated stage between 2007 and 2012. Patients with PH-LHD were divided into 3 groups according to the value of DPG and TPPG (Non-PVD group: DPG <7mmHg and TPPG ≤12mmHg; TPPG-PVD group: DPG <7mmHg and TPPG >12mmHg; DPG-PVD group: DPG ≥7mmHg). Multivariate Cox regression analysis was applied to investigate whether each PH-LHD category predicts death or HF readmission after adjusting for other variables. RESULTS: PH-LHD was observed in 164 patients (40%) with symptomatic HF. Thirteen patients (3%) were allocated into DPG-PVD group, while 24 patients were allocated into TPPG-PVD group (6%). DPG-PVD group was significantly associated with death or HF readmission compared to non-PVD group (hazard ratio: 3.57; 95% CI: 1.33 to 9.55, p=0.01), while the association between TPPG-PVD group and non-PVD group did not reach statistical significance (hazard ratio: 1.89; 95% CI: 0.77 to 4.64, p=0.17). CONCLUSIONS: PH-LHD with PVD classified by DPG was significantly associated with poor long-term clinical outcomes, whereas the association between PH-LHD with PVD classified by TPPG and clinical outcomes did not reach statistical significance. However, further studies are needed, because there was no substantial difference in clinical outcomes between PH-LHD with PVD classified by DPG and PH-LHD with PVD classified by TPPG.

Lower 1,5-anhydroglucitol is associated with adverse clinical events after percutaneous coronary intervention.

Diabetes mellitus and impaired glucose tolerance are well-known risk factors for coronary artery disease (CAD) and adverse clinical events after percutaneous coronary intervention (PCI). Postprandial hyperglycemia is an important risk factor for CAD and serum 1,5-anhydroglucitol (1,5-AG) reflects postprandial hyperglycemia more robustly than hemoglobin (Hb)A1c. We aimed to clarify the relationship between serum 1,5-AG level and adverse clinical events after PCI. We enrolled 141 patients after PCI with follow-up coronary angiography. We evaluated associations between glycemic biomarkers including HbA1c and 1,5-AG and cardiovascular events during follow-up. Median serum 1,5-AG level was significantly lower in patients with any coronary revascularization and target lesion revascularization (TLR) [13.4 µg/ml (first quartile, third quartile 9.80, 18.3) vs. 18.7 (12.8, 24.2), p = 0.005; 13.4 µg/ml (10.2, 16.4) vs. 18.7 (12.9, 24.2), p = 0.001, respectively]. Multivariate logistic analysis showed lower 1,5-AG was independently associated with any coronary revascularization and TLR (odds ratio 0.93, 95 % confidence interval 0.86-0.99, p = 0.04; 0.90, 0.81-0.99, p = 0.044, respectively), whereas higher HbA1c was not. Postprandial hyperglycemia and lower 1,5-AG are important risk factors for adverse clinical events after PCI.

Circadian variation of acute aortic dissection.

Acute aortic dissection (AAD) is a life-threatening cardiovascular disease with high mortality. Hypertension is a well known risk factor of AAD. There have been previous reports about the association between circadian variation of blood pressure (BP) and cardiovascular events. However, little is known about the association between the onset-time of AAD and circadian variation of BP. The purpose of this study was to clarify the characteristics of circadian variation of BP in AAD and its relation to the onset-time of this disease. This study included type B spontaneous AAD patients who were referred to our institution and treated conservatively between January 2008 and June 2013. Patients with type A AAD, secondary to trauma, and type B AAD which preceded surgical intervention were excluded. Data were retrospectively collected from the hospital medical records. Sixty-eight patients with type B AAD were enrolled. The distribution of the circadian pattern in the study patients was as follows: extreme-dipper, 0% (none); dipper, 20.6% (n = 14); nondipper, 50% (n = 34); riser, 29.4% (n = 20). Non-dipper and riser patterns were more frequently observed compared with other population studies reported previously. Moreover, no patient in the dipper group had night-time onset while 31.5% of the patients in the absence of nocturnal BP fall group (non-dipper and riser) did (P = 0.01). Absence of a nocturnal BP fall was frequently seen in AAD patients. Absence of a nocturnal BP fall may be a risk factor of AAD. Circadian variation of BP may also affect the onset-time of type B AAD.

Prognosis of patients with fulminant myocarditis managed by peripheral venoarterial extracorporeal membranous oxygenation support: a retrospective single-center study.

BACKGROUND: Peripheral venoarterial extracorporeal membranous oxygenation (ECMO) support is effective in patients with cardiogenic shock or fatal arrhythmia due to fulminant myocarditis. The clinical courses of fulminant myocarditis are still uncertain; therefore, it is difficult to determine the appropriate time for discontinuing ECMO or converting to a ventricular assist device. The purpose of this study was to investigate the prognosis of patients with fulminant myocarditis managed by ECMO. METHODS: Twenty-two consecutive patients with fulminant myocarditis managed by peripheral venoarterial ECMO between 1999 and 2013 were enrolled. RESULTS: Survival to discharge was 59% (13 patients), and in-hospital mortality was 41% (9 patients). The age in the survivor group was significantly lower than that in the non-survivor group (survivor group vs. non-survivor group; 36.5 ± 4.1 vs. 60.2 ± 5.0 years, p = 0.001). Although the ECMO support duration was similar between the groups (181 ± 22 vs. 177 ± 31 h), the rate of complication related to ECMO was significantly lower in the survivor group (15.3% vs. 66.6%, p = 0.02). When comparing the laboratory data during ECMO management between the groups, the serum bilirubin level on day 7 was significantly lower in the survivor group (total: 4.6 ± 2.8 vs. 13.7 ± 10.8 mg/dL, p = 0.014; direct: 2.2 ± 0.5 vs. 9.8 ± 4.5 mg/dL, p = 0.009). CONCLUSIONS: Fulminant myocarditis is associated with high mortality rates despite ECMO. An older age and complications related to ECMO are associated with poor prognosis.

Lower 1,5-anhydroglucitol is associated with denovo coronary artery disease in patients at high cardiovascular risk.

Postprandial hyperglycemia is a risk factor for cardiovascular disease and mortality. Serum 1,5-anhydroglucitol (1,5-AG) level is an useful clinical marker of glucose metabolism which reflects postprandial hyperglycemia more robustly compared to hemoglobin A1c (HbA1c). Relationship between serum 1,5-AG level and cardiovascular disease has been reported; however, comparison between HbA1c and 1,5-AG as markers of cardiovascular disease was not performed. We included 227 consecutive patients who underwent coronary angiography meeting the following inclusion criteria: (1) patients who had no history of coronary artery disease (CAD); (2) patients without acute coronary syndrome; (3) patients without poorly controlled diabetes mellitus; (4) patients without anemia, liver dysfunction, acute, and chronic renal failure and malnutrition; and (5) patients without adhibition of acarbose or Chinese herbal medicine. We measured HbA1c, glycoalbumin, and 1,5-AG. Serum 1,5-AG was significantly lower in patients with CAD (16.6 ± 8.50 vs. 21.1 ± 7.97 µg/ml, P < 0.001). Multivariable logistic regression analysis showed decrease in serum 1,5-AG was independently associated with the presence of denovo CAD (0.93, 95% CI 0.88-0.98, P = 0.006). Serum 1,5-AG was also independently associated with the presence of denovo CAD in patients without diabetes mellitus (0.94, 95% CI 0.88-0.99, P = 0.046). In conclusion, lower serum 1,5-AG was associated with the presence of denovo CAD. Serum 1,5-AG may identify high cardiovascular risk patients for denovo CAD in both diabetic and non-diabetic patients.

Dipeptidyl peptidase-4 inhibitors are associated with improved left ventricular diastolic function after acute myocardial infarction in diabetic patients.

Dipeptidyl peptidase-4 (DPP4) is an integral membrane glycoprotein that modulates the pathological state of diabetes mellitus (DM), and DPP4 inhibitors are a new class of anti-type-2 DM drugs. Recent preclinical studies have associated DPP4 inhibition with improved myocardial systolic and diastolic function. Based on preclinical findings, we investigated associations between the administration of DPP4 inhibitors and cardiac function after acute myocardial infarction (AMI) in a clinical setting. We enrolled 34 patients with diabetes who were treated for acute myocardial infarction at our hospital between January 2010 and December 2012. We retrospectively compared changes in cardiac parameters determined by trans-thoracic echocardiography between patients treated with (DPP4-I group; n = 13) or without (non-DPP4-I group; n = 21) a DPP4 inhibitor during follow-up. The values of E/e' and of e'/a' significantly decreased and increased, respectively, in the DPP4-I, compared with the non-DPP4-I group (-2.53 ± 5.53 vs. 2.58 ± 5.68, p = 0.038 and 0.08 ± 0.23 vs. -0.12 ± 0.21, p = 0.036, respectively). We concluded that DPP4 inhibitors could improve E/e' and e'/a' in patients with DM and AMI and thus might be effective for treating left ventricular diastolic failure.

Cardiovascular and bleeding risk of non-cardiac surgery in patients on antiplatelet therapy.

BACKGROUND: The perioperative risk of non-cardiac surgery (NCS) in the patients on antiplatelet therapy after percutaneous coronary intervention (PCI) remains unclear. METHODS: This study was a retrospective and single center study. Between January 2008 and December 2011, 198 patients who had already received PCI underwent NCS in our hospital. Among them, 63 patients underwent surgery on dual antiplatelet therapy (DAPT group) and 88 patients on single antiplatelet therapy (SAPT group). We compared bleeding events and cardiovascular events during perioperative period between the two groups. RESULTS: There was no stent thrombosis in either group. The bleeding events in the DAPT group were significantly higher than that in the SAPT group (9.5% vs 2.3%, p=0.049). There was no difference in events between with or without heparin-bridge in the SAPT group. CONCLUSIONS: The frequency of bleeding events was higher in the DAPT group. Both bleeding and cardiovascular events with aspirin alone were low in our study. It may be safe to undergo NCS with SAPT after PCI.

Effect of chronic statin treatment on vascular remodeling determined by intravascular ultrasound in patients with acute myocardial infarction.

Early statin treatment of patients with acute coronary syndrome results in vascular changes and improved clinical outcomes. However, the influence of chronic statin treatment on the culprit vessel in acute coronary syndrome is not fully understood. The aim of this study was to investigate the morphologic features of the culprit vessel in acute myocardial infarction by comparing patients with and without chronic statin treatment. We enroled consecutive patients with AMI, who had hyperlipidemia and primary percutaneous coronary intervention guided by intravascular ultrasound within 24 hours of symptom onset. Of 155 patients, 73 patients were stratified to the chronic statin group and 82 to the nonstatin group. Intravascular ultrasound in both the groups showed that positive remodeling was significantly less frequent in the chronic statin group (46.6%) compared with the nonstatin group (70.7%; p = 0.001). Necrotic core area was significantly smaller in the chronic statin group (2.2 ± 1.3 mm(2)) compared with the nonstatin group (3.2 ± 2.1 mm(2); p <0.001). Multivariate logistic regression analysis revealed that chronic statin treatment was significantly associated with less positive remodeling (odds ratio 0.283, 95% confidence interval 0.111 to 0.723, p = 0.008). In conclusion, chronic statin treatment reduced positive remodeling in the culprit lesions of patients with acute myocardial infarction.

Transient no reflow following primary percutaneous coronary intervention.

No reflow following primary percutaneous coronary intervention (PCI) is a serious complication in the treatment of acute myocardial infarction. No reflow in some patients is reversible (transient no reflow), whereas no reflow in others persists until the end of the procedure (persistent no reflow). The aim of this study was to identify clinical features of transient no reflow following primary PCI. Consecutive patients with no reflow (n = 123) were enrolled following primary PCI. Among them, 59 patients were in the transient group and 64 in the persistent group. We compared clinical features and hospital outcomes between the two groups. Multivariate logistic regression analysis was performed to identify the determinants of transient no reflow. The transient group had a lower rate of in-hospital cardiac death than the persistent group (0 vs. 6.4 %, relatively, P = 0.018). There was a trend for a shorter length of hospital stay in the transient group. Multivariate logistic regression analysis identified initial thrombolysis in myocardial infarction (TIMI) flow grade 3 (OR 6.239, 95 % CI 1.727-22.541, P = 0.005) and a higher estimated glomerular filtration rate (OR 1.204, 95 % CI 1.006-1.440, P = 0.042) as independent predictors of transient no reflow. Transient no reflow tended to be associated with TIMI thrombus grade ≤3 (OR 2.879, 95 % CI 0.928-8.931, P = 0.067). In conclusion, initial TIMI flow grade 3 and preserved renal function were associated with recovery from no reflow. Initial angiographic finding such as TIMI flow or TIMI thrombus grade might be an important predictor of recovery from the no-reflow phenomenon.

Clinical features of infective endocarditis: comparison between the 1990s and 2000s.

BACKGROUND: The circumstances surrounding infective endocarditis (IE) are under constant change due to an increase in drug-resistant organisms, a decrease in rheumatic valve disease, progress in surgical treatment, and aging society. The purpose of this study was to compare clinical features of IE between the 1990s and 2000s and to elucidate the determinants of death or clinical event. METHODS: All hospital admission records between January 1990 and December 2009 were retrospectively analyzed. The definition of IE was based on modified Duke criteria. Clinical presentation, blood culture, laboratory results, and echocardiography findings were compared between the 1990s and 2000s. RESULTS: There were 112 patients with definite or probable IE according to modified Duke criteria. The most frequent organism causing IE was Streptococcus viridians both in the 1990s and 2000s. The determinants of in-hospital death were hemodialysis and congestive heart failure. The in-hospital mortality of IE was 5.4% in the 1990s and 13.3% in the 2000s. Composite events of in-hospital death and central nervous system disorders were significantly higher in the 2000s compared with the 1990s. CONCLUSION: The most frequent causative organism of IE was S. viridians, both in the 1990s and 2000s. Independent predictors of in-hospital mortality in IE were hemodialysis and congestive heart failure.

Clinical features of myocardial infarction in young Japanese patients.

Clinical features and outcomes of acute myocardial infarction (AMI) in the young have been poorly investigated. The aim of this study was to investigate the clinical features and hospital outcomes of AMI in young Japanese. We conducted a case-control study. A total of 53 consecutive AMI patients whose age was ≤ 45 years old were assigned to the young group and 106 AMI patients whose age was > 45 years old were assigned to the non-young group. We compared the clinical features and hospital outcomes between the two groups. Compared with the non-young group, the young group was associated with male sex, hyperlipidemia, current smoking, being overweight, single vessel disease, and Killip class I on admission. There were no differences in the length of hospital stay or major adverse cardiac events between the groups. However, mortality and ventricular rupture were slightly lower in the young. In conclusion, young AMI patients had clinical characteristics different to those of the non-young patients. Compared to non-young patients, modifiable risk factors such as smoking, hyperlipidemia, and being overweight were associated with young AMI patients.