1-year outcomes of patients implanted with the Perceval sutureless valve: the Japanese post-marketing surveillance study.

Sutureless offers an alternative to standard valves in surgical aortic valve replacement (SAVR). We sought to confirm the efficacy and safety of the Perceval sutureless valve in Japanese patients. Prospective observational study of 204 patients who underwent SAVR with Perceval at 19 sites in Japan between March and December 2019. The primary outcomes were 30-day mortality and postoperative complications; the secondary outcome was all-cause mortality at 1 year. Efficacy outcomes were changed in New York Heart Association (NYHA) class, pressure gradients, effective orifice area (EOA), EOA indexed to body surface area (EOAi) and severity of aortic regurgitation. Mean age was 77.7 years, 62.7% were female. Procedural success rate was 99.0%. The median cross-clamp and cardiopulmonary bypass times were 68.0 and 108 min. Perceval size S and M were implanted in 95 (46.6%) and in 76 (37.3%) of patients, respectively. The 30-day and late mortality rate were 0.5% and 4.4%, while the new permanent pacemaker implantation rate was 4.4%. Mean pressure gradient was 13.0 mmHg at discharge, reaching 11.0 mmHg at 1 year; while the mean EOA was 1.5 cm2 at discharge remaining stable up to 1 year. No moderate or severe leakages were present at discharge or at 1 year. NYHA class improved by ≥ 1 level in 55.1% of the patients at discharge and in 69.4% of the patients at 1 year. 1-year outcomes of SAVR with the Perceval sutureless valve in Japanese patients were favorable. This valve offers a promising alternative to conventional biological AVR in this Japanese population.

Surgical treatment of acute aortic dissection in a patient with SLE and prior antiphospholipid syndrome on therapy for over 30 years: a case report.

BACKGROUND: In patients with systemic lupus erythematosus (SLE), lengthy treatment and long-term steroid use are the main risk factors for developing aortic aneurysms or aortic dissections. In patients with cardiac tamponade, hemodynamic collapse may lead to acute renal and hepatic failure. CASE PRESENTATION: We report the successful treatment of a 55-year-old woman with SLE since the age of 21. She suddenly felt chest pain approximately 2 weeks before developing fever and vomiting and was admitted to our hospital. Initially, she had severe liver dysfunction and was admitted to the hepatology department, where treatment for fulminant hepatitis was initiated. However, computed tomography (CT) showed an acute aortic dissection (DeBakey type II) and severe bloody pericardial effusion. Therefore, we performed emergency pericardial drainage. Plasma exchange therapy was initiated as emergency aortic surgery was deemed impossible due to impaired liver function tests and coagulation. Ten days later, the patient developed peritonitis due to small bowel perforation, and laparotomy was performed for abscess drainage and perforation closure. She had received steroid pulse therapy at the age of 21. At 40 years of age, she developed deep vein thrombosis due to antiphospholipid antibodies and was prescribed prednisolone. She was ambulatory at 3 months after the onset of acute aortic dissection, and CT revealed a rapidly enlarging true aneurysm in the distal arch. We performed elective aortic surgery. Although there were no antiphospholipid antibodies, surgery could have led to a devastating antiphospholipid syndrome. Therefore, we decided to treat the patient with triple therapy. Methylprednisolone was intravenously administered intraoperatively and at 1 day postoperatively. The patient was discharged without complications after returning to her usual oral prednisolone regimen. CONCLUSIONS: The patient described herein had a systemic circulatory failure due to cardiac tamponade, accompanied by liver failure. This condition is a significant cause of death in patients with aortic dissection-associated SLE and is extremely dangerous. However, multi-specialty intervention helped the patient recover, and she has been attending the outpatient clinic. Aortic surgery requiring hypothermia in SLE patients with antiphospholipid syndrome and a history of thrombocytopenia or thrombosis requires a multi-disciplinary treatment team, including cardiac surgeons and medical experts.

Novel Technique for Tetralogy of Fallot Repair with Transannular Patch Using Pedicled Own Pericardium.

In the surgical repair of the tetralogy of Fallot with a narrow pulmonary valve annulus, the transannular patch method is used for right ventricular outflow tract repair. To prevent pulmonary regurgitation and valve calcification, we created and applied a new transannular patch method using pedicled own pericardium in a 5-month-old boy with tetralogy of Fallot. After closing the ventricular septal defect as usual with a 0.4 mm Gore-Tex sheet, we decided that the pulmonary valve could not be spared, because the pulmonary valve opening size was 6 mm. After removing the right ventricular abnormal myocardium, each edge of the pedicled own pericardium patch was sewn from 5 mm above the pulmonary valve commissures toward the basis of the pulmonary valve ring. The transannular patch was created using a Gore-Tex graft sawn to the right ventricular outflow tract. Echocardiography performed 6 months post surgery showed no pulmonary stenosis and trivial pulmonary insufficiency.

Relationship between skin autofluorescence levels and clinical events in patients with heart failure undergoing cardiac rehabilitation.

BACKGROUND: Advanced glycation end-products, indicated by skin autofluorescence (SAF) levels, could be prognostic predictors of all-cause and cardiovascular mortality in patients with diabetes mellitus (DM) and renal disease. However, the clinical usefulness of SAF levels in patients with heart failure (HF) who underwent cardiac rehabilitation (CR) remains unclear. This study aimed to investigate the associations between SAF and MACE risk in patients with HF who underwent CR. METHODS: This study enrolled 204 consecutive patients with HF who had undergone CR at our university hospital between November 2015 and October 2017. Clinical characteristics and anthropometric data were collected at the beginning of CR. SAF levels were noninvasively measured with an autofluorescence reader. Major adverse cardiovascular event (MACE) was a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data concerning primary endpoints were collected until November 2017. RESULTS: Patients' mean age was 68.1 years, and 61% were male. Patients were divided into two groups according to the median SAF levels (High and Low SAF groups). Patients in the High SAF group were significantly older, had a higher prevalence of chronic kidney disease, and more frequently had history of coronary artery bypass surgery; however, there were no significant between-group differences in sex, prevalence of DM, left ventricular ejection fraction, and physical function. During a mean follow-up period of 590 days, 18 patients had all-cause mortality and 36 were hospitalized for HF. Kaplan-Meier analysis showed that patients in the high SAF group had a higher incidence of MACE (log-rank P < 0.05). After adjusting for confounding factors, Cox regression multivariate analysis revealed that SAF levels were independently associated with the incidence of MACE (odds ratio, 1.86; 95% confidence interval, 1.08-3.12; P = 0.03). CONCLUSION: SAF levels were significantly associated with the incidence of MACE in patients with HF and may be useful for risk stratification in patients with HF who underwent CR.

Safety and efficacy of using cereal food (Frugra®) to improve blood pressure and bowel health in patients undergoing chronic hemodialysis: A pilot study.

Hypertension and constipation are major hemodialysis complications. Salt restriction is one of the most important nonpharmacological interventions in managing hypertension. In patients undergoing hemodialysis, nonpharmacological strategies to manage constipation are extremely difficult to develop owing to the presence of excess dietary potassium and fluids. Frugra®, which is a cereal food that has a low salt content of 0.5 g per serving, may help reduce salt intake. Additionally, Frugra is rich in dietary fiber, thereby beneficial for such patients. In this study, we evaluated the safety and efficacy of Frugra in patients undergoing hemodialysis, focusing mainly on blood pressure and bowel health by changing the usual breakfast meal to Frugra for 8 weeks. We enrolled 11 patients undergoing hemodialysis. Despite the absence of changes in the patients' dry weight levels, their systolic blood pressure levels decreased from 155.5 ± 20.9 mmHg to 137.9 ± 10.3 mmHg after 2 months (P < 0.05). All participants reported improvements in bowel movement, and the levels of indoxyl sulfate, a representative gut-derived uremic toxin, were decreased from 49.3 µg/ml to 33.4 µg/ml. Furthermore, adverse events including electrolyte abnormalities were not observed. Therefore, Frugra may be useful to manage the health of patients undergoing hemodialysis.

Rapid decline in cardiac function in diabetic patients with calcified coronary artery disease undergoing hemodialysis: two case reports.

BACKGROUND: Clinical symptoms of patients on dialysis do not match the signs of coronary disease progression, making the prediction of the true progression of their medical condition in clinical settings difficult. Emergency and concomitant surgeries are significant risk factors of mortality following open-heart surgery in patients on hemodialysis. CASE PRESENTATION: We report two cases of successful coronary artery bypass grafting (CABG) in patients on dialysis with a history of cardiac surgery. The first case describes a 65-year-old woman who had undergone aortic valve replacement 2 years ago and was hospitalized urgently, because of a sudden decline in heart function and hypotension. She had moderate mitral regurgitation with right ventricular pressure of 66 mmHg and poor left ventricular function [left ventricular ejection fraction (LVEF), 40%]. Cineangiography revealed an increase in the rate of stenosis in the left main trunk, from 25 to 99% at admission, in addition to 100% occlusion in proximal left anterior descending artery (LAD) and 99% stenosis in the proximal left circumflex artery (LCX). We inserted an intra-aortic balloon pump preoperatively and performed emergency surgery (Euro II risk score, 61.7%; Society of Thoracic Surgeons (STS) risk score, 56.3%). The second case described a 78-year-old man who had undergone surgery for left atrial myxoma 4 years ago and was hospitalized urgently due to dyspnea, chest discomfort, and an LVEF of 44% (Euro II risk score, 40.7%; STS risk score, 33.2%). Cineangiography revealed an increase in the rate of stenosis in the proximal LAD, from 25% (4 years ago) to 90% at admission, in addition to 99% stenosis in proximal LCX and 95% stenosis in the posterolateral branch of LCX. Both patients underwent emergency CABG due to unstable hemodynamics and decreased left ventricular function despite regular dialysis. The surgeries were successful, and the patients were discharged without any complications. CONCLUSIONS: In patients with multiple comorbidities and those who undergo dialysis treatment, calcified lesions in coronary arteries can progress severely and rapidly without any symptoms, including chest pain. Close outpatient management involving nephrologists and the cardiovascular team is necessary for patients on dialysis.

A new technique that prevents paravalvular leakage after aortic valve replacement using a rapid-deployment valve system.

BACKGROUND: We report our 1-year single-center experience of a new technique of aortic valve replacement using a rapid-deployment valve (RD-AVR) to avoid postoperative complications. We also report the unexpected pitfalls and handling techniques that we have seen in past cases. METHODS: We performed aortic valve replacement on 38 patients between May 2019 and April 2020. Their mean age was 74 years. The primary outcomes were in-hospital mortality and short-term results during a 1-year follow-up period, while the secondary outcomes were related to prosthetic valve function, especially paravalvular leakage (PVL). We further analyzed the relationship between the new technique and its outcomes. RESULTS: The mean operative time was 196 min. There were no in-hospital deaths, and the mean duration of postoperative hospital stay was 11.8 days. Valvular measurements using three-dimensional computed tomography were larger and more accurate than those measured using ultrasonic echocardiography. Postoperative RD-AVR prosthetic valve function was excellent. However, PVL occurred in four cases 1 week and 1 year postoperatively and regurgitation did not improve. A gap associated with PVL was identified below the right-noncoronary commissure. To prevent PVL, we additionally stitched this gap in the later 18 cases; there was no case of PVL and no new pacemaker implantation in these cases. CONCLUSIONS: PVL is more likely to occur if there is a gap below the R-N commissure, especially in cases with a large annulus; therefore, applying an additional stitch to the R-N commissure is extremely useful.

Rapid-Deployment Aortic Valve Replacement for a Hemodialysis Patient with Prior Coronary Artery Bypass Grafting.

BACKGROUND: Aortic valve reoperation increases the risk of mortality and morbidity. The 2017 European Society of Cardiology guidelines for managing valvular heart disease with a previous heart surgery and intact bypass grafts consider patients with high surgical risk to be injury-prone during sternotomy. In high-risk patients with prior coronary artery bypass grafting, several authors have reported the noninferiority or superiority of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement; however, in Japan, TAVR cannot be performed for patients on hemodialysis. In this study, we report a case of successful implantation of the new rapid-deployment bioprosthesis in a 65-year-old Japanese man on dialysis with prior coronary artery bypass grafting. METHODS: The rapid-deployment aortic valve system has demonstrated excellent hemodynamic performance, durability, and safety. However, implantation requires specific training and the analysis of preoperative 3D computed tomographic imaging. The cineangiography revealed patency of all grafts, and the saphenous vein graft (SVG) had overlapped the planned aortotomy position. By avoiding the anastomotic part of the SVG, we could perform rapid-deployment aortic valve replacement efficiently even if the aortic incision was repositioned, and the incision was smaller than planned. RESULTS: We used the 23-mm Intuity valve without an additional stitch, and the cardiopulmonary bypass and aortic cross-clamp times were only 52 and 39 minutes, respectively. CONCLUSION: This novel valve may be beneficial in complex combinational procedures for hemodialysis patients with prior coronary artery bypass grafting.

Efficacy and safety of insulin glargine/lixisenatide fixed-ratio combination (iGlarLixi) in Japanese patients with type 2 diabetes mellitus inadequately controlled on basal insulin and oral antidiabetic drugs: The LixiLan JP-L randomized clinical trial.

AIMS: To assess efficacy and safety of fixed-ratio (1:1) combination insulin glargine and lixisenatide (iGlarLixi) compared to insulin glargine U100 (iGlar), with metformin, in Japanese patients with type 2 diabetes mellitus (T2DM) inadequately controlled on basal insulin and oral antidiabetic drugs (OADs). MATERIALS AND METHODS: This 26-week, randomized, open-label study compared iGlarLixi to iGlar, both with metformin in adult Japanese patients with T2DM and hemoglobin (Hb) A1c ≥7.5% to ≤9.5%, treated with basal insulin and 1 or 2 OADs. Five hundred and twelve patients were randomized after a 12-week run-in, when iGlar was introduced and/or further titrated and OADs other than metformin were stopped. The primary endpoint was change in HbA1c from baseline to week 26. RESULTS: iGlarLixi (n = 255) demonstrated significantly greater reductions in HbA1c (-1.27%) than iGlar (n = 257, -0.53%) (LS mean difference: -0.74%, P < .0001) at week 26, confirming the superiority of iGlarLixi. Significantly, more iGlarLixi patients reached target HbA1c <7% at week 26 (51.8% vs 16.0% for iGlar). iGlarLixi patients lost weight in contrast to iGlar patients (-0.51 kg vs +0.55 kg). Documented symptomatic hypoglycemia (plasma glucose ≤ 3.9 mmol/L) was observed in 18.8% of iGlarLixi patients vs 16.7% of iGlar patients. iGlarLixi patients had more gastrointestinal-related adverse events than iGlar patients (33.3% vs 8.6%), primarily nausea (16.9% vs 0.8%). However, the treatment was generally well-tolerated. CONCLUSIONS: A once-daily injection of iGlarLixi with metformin is an effective, well-tolerated, and simple therapeutic intervention providing significant improvement in glycemic control in Japanese patients with T2DM inadequately controlled on basal insulin and up to two OADs. Clinical Trial Number: NCT02752412.

Efficacy and safety of insulin glargine/lixisenatide fixed-ratio combination (iGlarLixi 1:1) in Japanese patients with type 2 diabetes mellitus inadequately controlled on oral antidiabetic drugs: A randomized, 26-week, open-label, multicentre study: The LixiLan JP-O2 randomized clinical trial.

AIMS: To assess efficacy and safety of 26-week treatment with insulin glargine/lixisenatide fixed-ratio combination (iGlarLixi) compared with insulin glargine U100 (iGlar) in Japanese patients with type 2 diabetes mellitus (T2DM) inadequately controlled on oral antidiabetic drugs (OADs). MATERIALS AND METHODS: This phase 3, multicentre, open-label, 1:1 randomized, parallel-group study compared efficacy of iGlarLixi and iGlar in patients with T2DM, HbA1c of ≥7.5% to ≤9.5% and fasting plasma glucose ≤10.0 mmol/L (180 mg/dL). The primary endpoint was change in HbA1c from baseline to week 26. RESULTS: Patients were randomized to iGlarLixi (n = 260) or iGlar (n = 261) (mean age 59.7 years, baseline BMI 26.04 kg/m2 , and HbA1c 8.04% [64.4 mmol/mol]). HbA1c reduction was significantly greater with iGlarLixi (-1.40% [-15.3 mmol/mol]) than with iGlar (-0.76% [-8.3 mmol/mol]). Significantly more iGlarLixi patients reached HbA1c <7% at week 26 (71.5% vs 38.5%, P < .0001), with significantly lower weight gain (LS mean difference -1.06 kg, P < .0001). Documented symptomatic hypoglycemia (plasma glucose ≤3.9 mmol/L [70 mg/dL]) was recorded in 14.2% of patients with iGlarLixi and 12.3% with iGlar. No severe hypoglycemia was reported in either group. Other than the expected gastrointestinal issues associated with glucagon-like peptide 1 receptor agonists, we found no major difference in the incidence of TEAEs. CONCLUSIONS: HbA1c reduction was significantly greater with iGlarLixi than with iGlar; significantly more patients achieved HbA1c <7%, with no additional risk of hypoglycemia and without weight gain. iGlarLixi (1:1) provided an effective treatment option for Japanese patients with T2DM inadequately controlled on OADs. Clinical Trial Number: NCT02752828.

Benefits of the fixed-ratio combination of insulin glargine 100 units/mL and lixisenatide (iGlarLixi) in Japanese people with type 2 diabetes: A subgroup and time-to-control analysis of the LixiLan JP phase 3 trials.

AIMS: To explore the impact of baseline characteristics on clinical outcomes in the phase 3 LixiLan JP trials which evaluated the efficacy and safety of iGlarLixi, a titratable fixed-ratio combination of insulin glargine 100 units/mL (iGlar) and GLP-1 RA lixisenatide (Lixi), vs Lixi (JP-O1, NCT02749890) or iGlar (LixiLan JP-O2, NCT02752828; JP-L, NCT02752412) in Japanese people with type 2 diabetes uncontrolled on oral antidiabetes drugs (OADs; JP-O1, JP-O2) or OADs and basal insulin (JP-L). MATERIALS AND METHODS: Glycated haemoglobin (HbA1c) change from baseline to week 26 was assessed within patient subgroups. Subgroups were defined by dipeptidyl peptidase-4 inhibitor use at screening (JP-O1, JP-O2 only), baseline HbA1c (<8%, ≥8%), baseline BMI (<25, ≥25 kg/m2) and age (<65, ≥65 years). Incidences of hypoglycaemia (baseline HbA1c, BMI and age subgroups) and gastrointestinal disorders (age subgroup) were evaluated over 52 (JP-O1) or 26 weeks (JP-O2, JP-L). Time to control (first HbA1c <7% or fasting plasma glucose [FPG] ≤130 mg/dL; JP-O2 only) was also assessed. RESULTS: HbA1c reductions were consistently greater with iGlarLixi vs iGlar or Lixi across all subgroups, and iGlarLixi was equally effective in all subgroups. Incidences of documented symptomatic hypoglycaemia (plasma glucose ≤3.9 mmol/L) were higher with iGlarLixi vs Lixi and generally comparable with iGlar. Across age subgroups, incidences of gastrointestinal disorders with iGlarLixi were higher vs iGlar, but lower vs Lixi. Median time to HbA1c or FPG control was shorter with iGlarLixi vs iGlar. CONCLUSIONS: iGlarLixi was consistently effective across all baseline characteristic subgroups, with more patients achieving glycaemic control vs iGlar early in treatment.

Association between the tissue accumulation of advanced glycation end products and exercise capacity in cardiac rehabilitation patients.

BACKGROUND: Advanced glycation end products (AGEs) are associated with aging, diabetes mellitus (DM), and other chronic diseases. Recently, the accumulation of AGEs can be evaluated by skin autofluorescence (SAF). However, the relationship between SAF levels and exercise capacity in patients with cardiovascular disease (CVD) remains unclear. This study aimed to investigate the association between the tissue accumulation of AGEs and clinical characteristics, including exercise capacity, in patients with CVD. METHODS: We enrolled 319 consecutive CVD patients aged ≥40 years who underwent early phase II cardiac rehabilitation (CR) at our university hospital between November 2015 and September 2017. Patient background, clinical data, and the accumulation of AGEs assessed by SAF were recorded at the beginning of CR. Characteristics were compared between two patient groups divided according to the median SAF level (High SAF and Low SAF). RESULTS: The High SAF group was significantly older and exhibited a higher prevalence of DM than the Low SAF group. The sex ratio did not differ between the two groups. AGE levels showed significant negative correlations with peak oxygen uptake and ventilator efficiency (both P <  0.0001). Exercise capacity was significantly lower in the high SAF group than in the low SAF group, regardless of the presence or absence of DM (P <  0.05). A multivariate logistic regression analysis showed that SAF level was an independent factor associated with reduced exercise capacity (odds ratio 2.10; 95% confidence interval 1.13-4.05; P = 0.02). CONCLUSION: High levels of tissue accumulated AGEs, as assessed by SAF, were significantly and independently associated with reduced exercise capacity. These data suggest that measuring the tissue accumulation of AGEs may be useful in patients who have undergone CR, irrespective of whether they have DM.

Reduced Number of Platelets During Intra-Aortic Balloon Pumping Counterpulsation Predicts Higher Cardiovascular Mortality After Device Removal in Association with Systemic Inflammation.

Thrombocytopenia is a frequent complication in patients requiring intra-aortic balloon pumping (IABP) counterpulsation. However, its prognostic impact has not been fully addressed. The objective of this study is to evaluate the impact of the change in the platelet number during IABP use on the prognosis after device removal.This is a retrospective observational study. Patients in the intensive cardiac care unit at three Juntendo University hospitals who underwent percutaneous implantation of IABP with or without veno-arterial extracorporeal membrane oxygenation (V-A ECMO), since 2012-2016, were enrolled in the study (n = 439). Patients who died during mechanical circulatory support (n = 47) were excluded. We evaluated the prognostic impact of the ratio of platelet reduction from the baseline (% PLT reduction) during IABP use on cardiovascular mortality after device removal.The median and the range of follow-up period were 298 days and 0-1,869 days, respectively. Unadjusted Kaplan-Meier analysis demonstrated that patients with a higher % PLT reduction had higher cardiovascular (CV) mortality. An adjusted Cox proportional hazard analysis demonstrated that a 10% higher % PLT reduction was associated with higher cardiovascular (CV) mortality (Hazard ratio: 1.3, 95% Confidence interval: 1.1-1.6, P < 0.001). Moreover, % PLT reduction and the maximum C-reactive protein (CRP) level during IABP use were positively correlated (r = 0.326, P < 0.001).The reduced number of platelets during IABP use was associated with an increased risk of CV mortality.

Independent Effect of Low Flow on Outcomes in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis.

BACKGROUND: Low flow (LF; i.e., reduced left ventricular stroke volume index <35 mL/m2) can occur with severe aortic stenosis (AS). However, few studies have investigated the effects of LF on early and late outcomes after aortic valve replacement (AVR) for severe AS.Methods and Results:In all, 285 severe AS patients undergoing isolated AVR at Juntendo University Hospital between August 2002 and August 2015 were enrolled in the study. In this cohort, 52 patients (18%) had LF. Compared with patients with normal flow (NF) severe AS, early postoperative mortality (9.6% vs. 1.2%; P=0.006), gastrointestinal complications (5.7% vs. 0.8%; P=0.04), and the duration of the intensive care unit (ICU) stay (81.7 vs. 35.3 h; P=0.02) were increased in LF patients with severe AS. LF was an independent predictor of early mortality (Model A, odds ratio [OR] 6.81, P=0.01; Model B, OR 6.69, P=0.01) and composite complications (Model A, OR 2.44, P=0.02). In propensity score-matched comparisons, early mortality (12.8% vs. 0%; P=0.02), composite complications (28.2% vs. 10.2%; P=0.04), and duration of ICU stay (97.4 vs. 22.1 h; P=0.006) were significantly increased in LF than NF patients. CONCLUSIONS: LF, as an important independent risk factor for postoperative mortality and morbidity, should be included in risk stratification and assessment in severe AS patients.

Chest X-Ray Revealed a Slowly Progressive Giant Right Coronary Artery Aneurysm in an Asymptomatic Patient.

A giant right coronary artery aneurysm (60 × 70 mm in size) was incidentally found by chest X-ray as an abnormal right atrial enlargement, and it needed surgical resection. Although the majority of giant coronary artery aneurysms present with symptoms of coronary ischemia, this case presented without any specific symptom. This study indicates that when chest X-ray shows abnormal atrial enlargement, a differential diagnosis of giant coronary artery aneurysm may need to be considered.

Continuous renal replacement therapy with a polymethyl methacrylate membrane hemofilter suppresses inflammation in patients after open-heart surgery with cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) induces a complex inflammatory response involving an increase in inflammatory cytokines, called postperfusion syndrome. Previous studies demonstrated that adsorption of the serum cytokines can reduce acute inflammation and improve clinical outcomes. In this study, patients were placed on continuous renal replacement therapy (CRRT) with a polymethyl methacrylate (PMMA) membrane hemofilter immediately after the start of an open-heart surgery with CPB and throughout the postoperative course to prevent postperfusion syndrome. The aim of this study was to assess whether continuous CRRT using a PMMA filter (PMMA-CRRT) could affect cytokine expression and improve perioperative outcomes. We designed a randomized controlled trial, which included 19 consecutive adult patients on maintenance dialysis and 7 consecutive adult patients who were not on maintenance dialysis (NHD group). Patients on maintenance dialysis were randomly divided into two groups: Ten patients who received CRRT with a polysulfone membrane hemofilter (PS group) and nine patients who received CRRT with a PMMA membrane (PMMA group). Blood samples were collected from the radial or brachial artery at five different time points. Comparisons between the PS, PMMA, and NHD groups revealed a significant main effect of time on changes in serum IL-6 and IL-8 concentrations (p < 0.01) and an interaction (p < 0.05) between time and group. Plasma IL-6 and IL-8 levels after surgery were significantly lower in the PMMA group than in the PS group, while other cytokines measured in this study were not significantly different. In addition, clinical outcomes were not significantly different between the groups. The continuous use of PMMA-CRRT throughout the perioperative period suppressed serum IL-6 and IL-8 concentrations, although there were no differences in clinical outcomes.

A new surgical procedure for type II total anomalous pulmonary venous drainage.

We report two cases of successful surgical repair of total anomalous pulmonary venous drainage. Our new surgical procedure for type IIa and IIb total anomalous pulmonary venous drainage has more advantages than the conventional rerouting method using an artificial or native pericardial patch.

[Aortic Root Replacement for Patients with Aortic Root Aneurysms;Clinical Outcomes Compared Among Different Types of Abnormality and Operative Procedures].

Aortic root operations are established procedures for patients with aortic root aneurysms, however there is a little insight for comparative long-term outcomes among different types of anatomical abnormalities and procedures. In this study, we sought to compare the results of patients with aortic abnormalities undergoing different procedures. From January 2008 to March 2017, a total of 105 patients without aortic dissection were performed the elective aortic root surgery. Patients with bicuspid aortic valve had enlarged annulus, and those with Marfan syndrome had enlarged Valsalva without enlarged annulus. Bentall operation with mechanical valve or bioprothetic valve was performed for patients with enlarged annulus and/or abnormal aortic cusp, and David operations for patients with normal cusps. This comparative study showed that these different procedures according to our policy were associated with reduced cardiac mortality and valve-related complications. The results suggest David procedure is the treatment of choice for young patients with aortic root aneurysm and normal aortic cusps, however, careful patient selection is paramount.

Push-Up Technique and Anatomical Deployment With the Endurant Stent-Graft System for Severely Angulated Aneurysm Necks.

PURPOSE: To describe a technique suitable for treating severely angulated (>75°) necks during endovascular aneurysm repair using the Endurant stent-graft. TECHNIQUE: In the push-up technique, the suprarenal stent is released early to fix the proximal stent-graft in place so that each stent in the neck can be deployed individually without displacing the device upward. It is important to push the delivery system up after each stent deployment to allow the fabric between the stents to fold up circumferentially. By doing so, there is minimal upward force applied to the suprarenal stent. Because the stents expand along the angulated neck while catching blood flow, this anatomical deployment is feasible, with hardly any change to the proximal neck shape after stent-graft implantation. CONCLUSION: The push-up technique and anatomical deployment with the Endurant stent-graft system are effective and safe methods for treating aneurysms with severely angulated necks.

Redo Tricuspid Valve Repair with Leaflet Augmentation Using the Left Atrial Wall.

The case is reported of a 79-year-old female who received a patch augmentation of the tricuspid anterior and septal leaflets with a resected left atrial wall to address recurrent tricuspid regurgitation, including tricuspid valve tethering. The patient was admitted to the authors' hospital for chronic heart failure with paravalvular leakage after aortic valve replacement and recurrent severe tricuspid regurgitation. She had undergone two previous cardiac surgeries. Re-tricuspid repair required an augmentation of the tricuspid valve leaflets in addition to tricuspid annuloplasty. As the autologous pericardium was unsuitable for a patch due to thickened and stiffened changes, the decision was taken to use a left atrial wall resected to reduce the size of giant left atrium, which was thin and easy to handle. This is the first report of tricuspid leaflet augmentation using a patch derived from the left atrial wall, which is a useful method in patients where pericardium is not available.