Cumulated ambulation score as predictor of postoperative mobility in patients with proximal femur fractures.

INTRODUCTION: The cumulated ambulation score (CAS) has been developed as an index for evaluating mobility in the early postoperative period. This study aimed to estimate the association between CAS and independent ambulation after surgery for proximal femur fractures. MATERIALS AND METHODS: This retrospective cohort study included 223 elderly patients who underwent surgery for proximal femur fractures and had independent ambulation before the injury. Multivariable logistic regression analyses with cognitive impairment, pre-injury Barthel index, and CAS as the test variables were used to predict independent ambulation at 2 weeks (model 1) and 3 months (model 2) postoperatively. We established scoring systems based on the modeling results. RESULTS: The number of patients with independent ambulation at 2 weeks and 3 months postoperatively was 115 and 169, respectively. Univariate analysis showed that the CAS was significantly associated with independent ambulation at 2 weeks and 3 months postoperatively. Multivariable analysis showed that models 1 and 2 had good predictive accuracies, with areas under the receiver-operating characteristic curve of 0.855 and 0.868, respectively. Among the explanatory variables, only the CAS in model 2 was not significantly associated with the postoperative ambulatory ability. Scoring systems for both models 1 and 2 also had good predictive accuracies, with cut-off scores of 3.5 for model 1 and 9.5 for model 2. CONCLUSIONS: The CAS predicted independent ambulation at 2 weeks postoperatively; however, this relationship was limited at 3 months postoperatively. Therefore, the CAS may help estimate independent ambulation at discharge from an acute-care hospital.

Transcatheter closure of patent foramen ovale accompanying right-to-left shunt during Impella support.

We experienced a 65-year-old woman who was diagnosed as fulminant myocarditis and transferred on mechanical ventilator and veno-arterial extracorporeal membrane oxygenation (ECMO) supports. Impella 5.0 support was additionally initiated to improve pulmonary edema and unload left ventricle. We found a patent foramen ovale (PFO) at the time of Impella insertion by transesophageal echocardiography. Follow-up transesophageal echocardiography found a development of right-to-left shunt flow through PFO accompanying central hypoxia during Impella P8 support. Veno-arterial ECMO was converted to veno-arterio-venous ECMO and PFO was occluded percutaneously on the next day, which stabilized hemodynamics and systemic oxygen supply. In case of Impella 5.0 support, the existence of PFO and the development of right-to-left shunt flow should be carefully surveyed and closed immediately to maintain hemodynamics and systemic oxygen supply.

The relationship between scapular position and glenohumeral rotational range of motion in high school baseball players.

BACKGROUND: Past research indicated that scapular malposition is related to the glenohumeral internal rotation deficit (GIRD). However, there is no research examining the effect of throwing-related pain on this relationship. This study investigated the relationship between scapular position and range of motion (ROM) and compared the difference in this relationship between with and without throwing-related pain. METHODS: Forty male baseball players in high school were recruited for this study. The existence and degree of throwing-related pain were obtained from a questionnaire. Participants were divided into 2 groups according to the presence or absence of the pain. Glenohumeral internal and external rotation ROM (abduction internal rotation angle and abduction external rotation angle [ABER], respectively) were measured using a digital inclinometer. The pectoralis minor muscle length was measured using a vernier caliper and scapula index, which indicated the scapular position, measured using a measuring tape. All these measurements were taken on both dominant and nondominant sides. The GIRD and total motion arc (TMA) deficit were calculated from the ROM measurements. Groups were compared using a mixed-model analysis of variance. RESULTS: There was a significant interaction between group and ABER dominance. Other variables were not seen as the interaction effect. There was a significant positive correlation between the scapula index and TMA (r = 0.47, P = .02) and a negative correlation between the scapula index and GIRD (r = -0.65, P < .01) in the dominant side of the pain group. In addition, in the nondominant side of the pain group, the scapula index and ABER were significantly correlated (r = 0.43, P = .04). CONCLUSIONS: The results of this study indicate that the scapular position is associated with the glenohumeral ROM in high school baseball players. In addition, this study demonstrated that the scapular internally rotated position was correlated with the GIRD and TMA deficit in high school baseball players who had throwing-related pain. On the other hand, the scapular externally rotated position was correlated with increased ABER, mainly in the pain-free baseball players or on the nondominant side. These results indicated that the scapular position might affect the glenohumeral rotational ROM in high school baseball players.

A Rescue Use of ECPELLA for Sepsis-Induced Cardiogenic Shock Followed by Mitral Valve Replacement.

The use of veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with sepsis-induced cardiogenic shock has been reported, but the clinical implication of the Impella percutaneous axial-flow left ventricular assist device for such patients remains unknown. We had a 37-year-old man with septic shock and severely reduced cardiac function. Veno-arterial ECMO and concomitant Impella CP support ameliorated his end-organ dysfunction and achieved cardiac recovery, whereas severe mitral valve regurgitation due to chordal rupture developed later. Mitral valve replacement concomitant with ECMO removal as well as an Impella upgrade successfully treated the patient. ECMO and Impella support might be an effective therapeutic strategy for the bridge to recovery in patients with sepsis-induced cardiogenic shock; however, paying attention to mitral chordal rupture is highly encouraged.

Trans-Apical Transcatheter Aortic Valve Replacement in a Dialysis Patient with Systolic Heart Failure.

Mortality and morbidity remain high following transcatheter aortic valve replacement (TAVR) in dialysis patients or those with low left ventricular ejection fraction. Therapeutic strategy for those with these comorbidities remains unestablished. We had a dialysis patient with peripheral artery disease and low left ventricular ejection fraction, who received successfully scheduled trans-apical TAVR following sufficient reverse remodeling by 3-month optimal medical therapy. Our strategy should be validated in a larger robust cohort.

Gait cycle time variability in patients with knee osteoarthritis and its possible associating factors.

[Purpose] Knee osteoarthritis can alter gait variability; however, few studies have investigated the associating factors with gait cycle time variability. The first objective was to compare gait cycle variability between female patients with knee osteoarthritis and healthy elderly females and to determine gait characteristics in patients with knee osteoarthritis. The second objective was to identify the associating factors with gait cycle time variability. [Participants and Methods] The participants included 24 female patients diagnosed with knee osteoarthritis and 12 healthy elderly females. Gait cycle variability (coefficient of variation of gait cycle time), knee extension range of motion, knee extension strength, 5-m walk test, Timed Up & Go Test, and Western Ontario and McMaster Universities Osteoarthritis Index were measured. All assessment results were compared between the knee osteoarthritis and healthy groups. [Results] Gait cycle time variability was significantly higher in the knee osteoarthritis group than in the healthy group. Further, it showed a significant positive correlation with the 5-m walk test and the Western Ontario and McMaster Universities Osteoarthritis Index. [Conclusion] Patients with knee osteoarthritis presented greater gait cycle variability than that of healthy individuals. Therefore, rehabilitation to improve gait variability might enhance the quality of life of patients with knee osteoarthritis.

Prognostic implication of risk scoring systems in patients with cardiogenic shock supported by ECMO and Impella.

We experienced two refractory cardiogenic shock patients receiving veno-arterial extracorporeal membrane oxygenation and Impella percutaneous left ventricular assist device (ECPELLA). TVAD score, which was originally proposed to predict one-year mortality following left ventricular assist device implantation using four objective parameters, was retrospectively calculated using data of day 3 following ECPELLA initiations. One patient with estimated intermediate risk could achieve successful explantation of ECPELLA, whereas another patient with estimated high risk was expired despite explantation of extracorporeal membrane oxygenation. TVAD score might be a useful tool to risk stratify and construct next strategy (i.e., bridge to recovery or bridge to more intensive therapy) for those with ECPELLA, although further studies are warranted to validate this hypothesis.

Peak Lag Between Plasma Vasopressin and Urine Aquaporin-2 Following Cardiac Surgery.

Tolvaptan, a vasopressin type-2 receptor antagonist, is utilized to ameliorate fluid retention following cardiac surgery. However, the optimal timing of tolvaptan administration considering novel biomarkers remains unknown. We prospectively included patients who underwent cardiac surgery between 2016 and 2020. We measured perioperative trends of free water reabsorption mediators including plasma arginine vasopressin and urine aquaporin-2. A total of 20 patients (68 [60, 75] years old, 18 men) were included. Urine volume decreased gradually after the initial 3 hours following cardiac surgery. The plasma arginine vasopressin level increased significantly with a peak at postoperative 6 hours, whereas the urine aquaporin-2 level increased later with a delayed peak at postoperative 12 hours. As a result, urine aquaporin-2 relative to the plasma arginine vasopressin level, which represents the activity of the collecting ducts and indicates predicted responses to tolvaptan, was a minimum at postoperative 6 hours. Tolvaptan administration immediately after cardiac surgery might not be recommended given the transient refractoriness to tolvaptan probably due to the stunning of kidney collecting ducts.

Lower limb kinematics of single-leg squat performance in patients with anterior cruciate ligament deficiency.

[Purpose] This study investigated the parameters that characterize the knee, hip, and pelvic kinematics during a single-leg squat in preoperative anterior cruciate ligament rupture injury. [Participants and Methods] Overall, 15 patients with unilateral anterior cruciate ligament deficiency were enrolled in this study. For each single-leg squat, data from two-dimensional video cameras and three-dimensional motion analysis were collected. Measurement indices included the articular angles of the knee, hip, and trunk. The anterior cruciate ligament-injured leg was compared with the uninjured leg. [Results] The maximum knee valgus and flexion angles during a single-leg squat were smaller in the injured leg than in the uninjured leg. During the single-leg squat, the effect of "compensatory mechanisms" appeared as knee valgus and flexion movements. In particular, the knee valgus angle decreased in the anterior cruciate ligament-injured leg compared to that in the uninjured leg. [Conclusion] This phenomenon suggests that it is possible to utilize recurrence prevention training for anterior cruciate ligament injury.

Impella support as a bridge to scheduled surgical repair of ventricular septal rupture.

We studied the experience of a 69-year-old woman with acute decompensated heart failure due to post-infarction ventricular septal rupture. She received mechanical hemodynamic support by Impella 2.5 (Abiomed, Danvers, MA, USA), percutaneous axial-flow left ventricular assist device, which improved intra-cardiac pressure, maintaining end-organ function. She was successfully bridged to the scheduled surgical repair of ventricular septal rupture following the 9-day Impella support and discharged on foot on the 32nd day. Impella might be a useful mechanical circulatory support device as a bridge tool to the scheduled surgical repair of ventricular septal rupture if used with careful daily management to prevent device-related comorbidities.

Congenital vascular ring.

A vascular ring is a rare congenital cardiovascular anomaly, which encircles and compresses the trachea or esophagus, or both. In this review we discuss the pathophysiology, theoretical embryopathogenesis, diagnostic modalities, and surgical treatment of the different types of vascular ring. Knowledge of the normal embryonic development of the aortic arch and related structures is important for understanding and classifying the various forms of vascular ring. The development of a vascular ring begins with the embryonic aortic arch system. The persistence, involution, or regression of the arches determines the multiple variations of vascular ring. With the development of new technologies, multi-detector computed tomography (MDCT) has become a good diagnostic modality for pre- and postoperative evaluation. MDCT provides an excellent image of aortic arch abnormalities and the related anatomy, as well as the tracheal pathology. For patients with symptoms, surgical division of the vascular ring usually achieves excellent outcomes with marked resolution of symptoms and a low risk of morbidity and mortality. Symptomatic vascular rings require early surgical intervention to prevent prolonged vascular compression of the airway and serious complications.

Paracorporeal Ventricular Assist Device Implantation in a Patient with Transposition of the Great Arteries After Senning Operation.

We experienced a 33-year-old patient with D-looped transposition of the great arteries (D-TGA) and a history of Senning operation who was referred to our institute with cardiogenic shock and subsequently underwent urgent paracorporeal ventricular assist device (VAD) implantation, which was a first in Japan, that was eventually converted to a durable VAD. Central venous pressure was maintained relatively high to obtain VAD filling and recover end-organ dysfunction, given the migration of the inflow cannula due to rich trabeculae carneae of the anatomical right ventricle (systemic ventricle in this case).

A case of cardiogenic shock due to acute coronary syndrome successfully recovered by percutaneous and paracorporeal left ventricular assist device.

We recently experienced a 70-year-old woman with left main trunk-acute coronary syndrome who was initially supported by Impella 5.0 which converted to paracorporeal left ventricular assist device (LVAD) implantation as a bridge to recovery. Optimized guideline-directed medical therapy with cardiac rehabilitation resulted in successful explantation of LVAD and she discharged on foot.

Transcatheter Aortic Valve Implantation Improves Cardiac Sympathetic Nerve Activity on 123I-Metaiodobenzylguanidine Myocardial Scintigraphy in Severe Aortic Valve Stenosis.

BACKGROUND: There is a consensus that overactivation of the cardiac sympathetic nervous system (CSN) proportionately increases the severity of heart failure and is accompanied by worse prognosis. Because it is unknown whether patients with aortic valve stenosis (AS) have similar CSN activation, we investigated the effect of transcatheter aortic valve implantation (TAVI).Methods and Results:We enrolled 31 consecutive patients with AS treated by TAVI. 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy was performed at baseline and at 2 weeks after TAVI. At baseline, the early heart-mediastinum ratio (H/M) was within normal limits (3.0±0.5), but the delayed H/M was low (2.6±0.6) and the washout rate (WR) was high (34±13%). WR negatively correlated with aortic valve area (r=-0.389, P<0.01) and cardiac output (r=-0.595, P<0.01) and positively correlated with norepinephrine (r=0.519, P<0.01) and log NT-proBNP level (r=0.613, P<0.01). After TAVI, there were significant decreases in the norepinephrine level (366±179 ng/mL vs. 276±125 ng/mL, P<0.01) and WR (34±13 vs. 26±11%, P<0.01). CONCLUSIONS: The WR of MIBG was a useful marker of CSN activity and severity of AS. Immediate improvement of CSN activity after TAVI implied that AS hemodynamics per se enhanced CSN.

[Early Results of Complex Fractionated Atrial Electrogram Mapping Guided Atrial Fibrillation Surgery].

OBJECTIVE: Although the Cox-maze operation is the standard surgical procedure for permanent atrial fibrillation(AF), conversion to sinus rhythm is limited by patient characteristics, including the duration of AF, atrial size, and voltage of fibrillation waves. A surgical strategy based on structural alteration of the electrical substrates of AF is required to achieve better outcomes of AF surgery. Complex fractionated atrial electrogram (CFAE) plays an important role in the electrical substrate of AF. We performed AF surgery guided by preoperative CFAE mapping using a 3-dimensional (3D) mapping system. This study evaluated the early results of our procedure. METHODS: From January 2015 to August 2016, 8 patients (mean age:66.5±6.4 years) underwent CFAE mapping-guided AF surgery. In the preoperative electrophysiological study using 3D mapping, CFAE was defined by a low voltage electrogram (0.05~0.25 mV) with a highly fractionated potential (short cycle length <120 msec). First, right atrial CFAE sites were ablated by using a catheter ablation system. Several days after right-sided CFAE ablation, a modified Cox-maze operation was performed with additional cryoablation of CFAE sites. RESULTS: There were 1~3 (mean:2.5 ±0.8) CFAE sites in the right atrium and 2~4 (mean:2.4±0.7) sites in the left atrium. Mean CFAE mapping time was 87.6±24.6 minutes, fluoroscopy time was 53.1±22.2 minutes, and volume of contrast agent was 44±3 ml. Concomitant cardiac surgery included mitral valve plasty in 6 patients, and aortic valve replacement and mitral valve replacement in 1 patient each. The mean time for CFAE mapping-guided AF surgery was 25.7±5.6 minutes. At discharge, 7 patients were in sinus rhythm and 1 patient still had AF, but sinus rhythm recovered at 3 months postoperatively without anti-arrhythmic medication. After a mean follow-up of 11.7±8.5 months, all patients remained in sinus rhythm. CONCLUSIONS: Early results suggest that CFAE mapping-guided atrial fibrillation surgery is feasible and effective. Although the long-term effect of CFAE ablation on maintenance of sinus rhythm and atrial function should be evaluated, this novel method could provide an alternative strategy for the surgical treatment of AF.

Warfarin Reversal With Four-Factor Prothrombin Complex Concentrate for Left Ventricular Assist Device Conversion Surgery Monitored by TEG6s: A Case Report.

Left ventricular assist devices (LVADs) require careful therapeutic anticoagulation with warfarin to prevent pump thrombosis. However, the best method to reverse warfarin for elective LVAD conversion surgery with massive bleeding remains unclear. We report the case of a 39-year-old Japanese man who was administered a four-factor prothrombin complex concentrate (4F-PCC) as warfarin reversal when he underwent conversion surgery from paracorporeal LVAD to implantable LVAD. 4F-PCC with co-administration of vitamin K reduced the international normalized ratio and R time in TEG6s (Haemonetics Corporation, USA) immediately. The effect was prolonged, and good hemostasis was achieved. 4F-PCC with vitamin K provided good hemostasis in our patient; therefore, 4F-PCC could be a useful tool for elective LVAD conversion surgery with expected massive bleeding and requiring immediate warfarin reversal.

An autopsy case of sudden unexpected death with Barlow's disease.

A 45-year-old man was clinically diagnosed with mitral valve regurgitation 2 years before death. The autopsy showed left ventricular hypertrophy and mitral valve prolapse of the bileaflet with billowing valve and excessively thickened leaflet, the findings of which were consistent with Barlow's disease. Microscopically, destruction of the 3-layer structure of the mitral valve and advanced interstitial fibrosis of the left ventricular wall were evident. Additionally, a marked but limited reduction in conduction fibers was found in the branching point of the left and right branches, as seen in cases of idiopathic complete atrioventricular block. Genetic investigation using whole-exome sequencing showed some genetic variants with uncertain significance. In patients with Barlow's disease, a marked reduction of conduction fibers might be a subtype of sudden cardiac death. The overlap of some arrhythmogenic substrate in the heart may increase the risk of sudden cardiac death with asymptomatic Barlow's disease.

Takayasu Arteritis Complicated by Ischemic Colitis: A Case Report.

Takayasu arteritis is an inflammatory disease of the aorta and its major branches, which results in stenosis and aneurysm formation. Lesions of the abdominal aorta and renal arteries are common. Nevertheless, lesions of the celiac and superior mesenteric arteries are less common. Since the inferior mesenteric artery is usually preserved and functions as a collateral pathway, developing intestinal ischemia is very rare in patients with Takayasu arteritis. In this study, we report the case of a patient with Takayasu arteritis complicated by ischemic colitis. The patient was treated with surgical repair, which resolved the patient's symptoms.

Mitral valve plasty in a patient with multiple cerebral cavernous malformations: A case report.

Cerebral cavernous malformations (CCMs) are blood vessel malformations, often untreated if asymptomatic. However, upon cardiac surgery with cardiopulmonary bypass, cerebral edema/hemorrhage may occur. We successful performed mitral valve plasty for a case of severe mitral regurgitation with multiple CCMs. Preoperative head magnetic resonance imaging and strict perioperative management are important.

A case of chronic myocarditis remitted by immunosuppressive and central extracorporeal membrane oxygenation therapy.

The concept and therapeutic strategy for chronic lymphocytic myocarditis remain unestablished. We had a 57-year-old man with advanced biventricular (predominantly right ventricular) failure due to chronic lymphocytic myocarditis. He received central extracorporeal membrane oxygenation therapy that was explanted on day 129 following the aggressive steroid pulse and plasma exchange therapy. Infiltration of inflammatory cells persisted even after the device removal, which required long-term oral steroid administration after the index discharge on day 200. High-sensitivity cardiac troponin T level was normalized and inflammatory cell infiltration was remitted following post-discharge 4-month 10 mg/day prednisolone therapy. Aggressive immunosuppressive therapy under mechanical circulatory support might be a promising strategy for those with chronic lymphocytic myocarditis. .