Bilateral pulmonary artery banding facilitates the systemic ventricular outflow tract growth for biventricular and univentricular repair candidates of complex arch anomaly.

Various surgical approaches address complex heart disease with arch anomalies. Bilateral pulmonary artery banding (bPAB) is a strategy for critically ill patients with complex arch anomalies. Some reports argued the potential effect of bPAB on the growth of the left ventricular outflow tract (LVOT) during inter-stage after bPAB. This study aimed to analyze the LVOT growth for biventricular repair candidates with arch anomaly and systemic ventricular outflow tract (SVOT) for univentricular repair candidates with arch anomaly. This retrospective study analyzed 17 patients undergoing initial bPAB followed by arch repair. The Z-scores of LVOT and SVOT were compared between pre-bPAB and pre-arch repair. Patient characteristics, transthoracic echocardiogram data, and PAB circumferences were reviewed. The diameter of the minimum LVOT for biventricular repair (BVR) candidates, the pulmonary valve (neo-aortic valve, neo-AoV) and the pulmonary trunk (the neo-ascending aorta, neo-AAo) for univentricular repair (UVR) candidates, and the degree of aortic or neo-aortic insufficiency in each candidate was statistically analyzed. 17 patients were divided into the UVR candidates (group U) with 9 patients and the BVR candidates (group B) with 8 patients. In group B, the median value of the Z-score of the minimum LVOT increased from -3.2 (range: - 4.1 ~ - 1.0) at pre-PAB to -2.8 (range: - 3.6 ~ - 0.3) at pre-arch repair with a significant difference (p = 0.012). In group U, the median value of the Z-score of the neo-AoV increased from 0.5 (range: - 1.0 ~ 1.7) at pre-bPAB to 1.2 (range: 0.2 ~ 1.9) at pre-arch repair with a significant difference (p < 0.01). The median value of the Z-score of the neo-AAo was also increased from 3.1 (range: 1.5 ~ 4.6) to 4.3 (range: 3.1 ~ 5.9) with a significant difference (p = 0.028). The growth of the LVOT for BVR candidates and SVOT for UVR candidates during the inter-stage between bPAB and arch repair was observed. These results suggest the potential advantage of bPAB in surgical strategies. Further research is needed to validate these findings and refine surgical approaches.

Thrombotic Mechanism Involving Platelet Activation, Hypercoagulability and Hypofibrinolysis in Coronavirus Disease 2019.

Coronavirus disease 2019 (COVID-19) has spread, with thrombotic complications being increasingly frequently reported. Although thrombosis is frequently complicated in septic patients, there are some differences in the thrombosis noted with COVID-19 and that noted with bacterial infections. The incidence (6-26%) of thrombosis varied among reports in patients with COVID-19; the incidences of venous thromboembolism and acute arterial thrombosis were 4.8-21.0% and 0.7-3.7%, respectively. Although disseminated intravascular coagulation (DIC) is frequently associated with bacterial infections, a few cases of DIC have been reported in association with COVID-19. Fibrin-related markers, such as D-dimer levels, are extremely high in bacterial infections, whereas soluble C-type lectin-like receptor 2 (sCLEC-2) levels are high in COVID-19, suggesting that hypercoagulable and hyperfibrinolytic states are predominant in bacterial infections, whereas hypercoagulable and hypofibrinolytic states with platelet activation are predominant in COVID-19. Marked platelet activation, hypercoagulability and hypofibrinolytic states may cause thrombosis in patients with COVID-19.

[Intraoperative Aortic Dissection during Mitral Valve Plasty:Report of a Case].

We report the case of a 74-year-old woman who underwent mitral valve plasty for mitral regurgitation. During the surgery, the ascending aorta was dilated and turned dark red after aortic cannulation. Intraoperative transesophageal echocardiography and direct epiaortic echography revealed type A aortic dissection. In addition to mitral valve plasty, replacement of the ascending aorta was performed under hypothermic circulatory arrest. The postoperative course was uneventful. Because intraoperative aortic dissection is a rare complication, its rapid identification and appropriate management is essential.

[Surgical Repair of Giant Coronary Artery Aneurysm Associated with Coronary-pulmonary Artery Fistulae;Report of a Case].

A 61-year-old woman was referred to our hospital with a complaint of chest compression. Coronary angiography revealed a giant coronary artery aneurysm, located in the middle of a coronary-pulmonary artery fistula originating from the right coronary artery. Another fistula was also shown between the left anterior descending artery and the pulmonary artery. Surgical correction was indicated due to the risks of the aneurysmal rupture and coronary events. Under cardiopulmonary bypass, suture-closure of the coronary artery aneurysm and ligations of the fistulae were carried. Postoperative coronary angiography showed no aneurysm or fistula, and she was discharged uneventfully on the 12th postoperative day.

[Giant Left Atrial Myxoma Found with Congestive Heart Failure;Report of a Case].

We report a case of giant left atrial myxoma in a 52-year-old woman who developed congestive heart failure. By echocardiography, not only the myxoma but moderate degree of mitral and tricuspid regurgitation was also found. The tumor was extensively attached to the left atrial endocardium, and was excised completely together with the endocardium. No valve surgery was added. Postoperative echocardiography showed no myxoma and no mitral valve regurgitation. She was discharged in good condition on postoperative day 14.

[Severe Calcification on Glutaraldehyde-treated Autologous Pericardium after Mitral Valve Repair by Leaflet Augmentation;Report of a Case].

We report a case of surgical treatment of mitral valve stenosis due to severe calcification on the glutaraldehyde-treated autologous pericardium. A 39-year-old woman presented with progressive dyspnea. She had undergone mitral valve repair by leaflet augmentation with a glutaraldehyde-treated autologous pericardium for mitral regurgitation 3 years before. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification was observed of the glutaraldehyde-treated autologous pericardium patch on the anterior mitral leaflet. Mitral valve replacement was performed successfully, and she was discharged on postoperative day 14.

[Surgery of Papillary Adenoma;Report of a Case].

A 59-year-old man consulted our hospital because of an abnormal shadow on a chest X-ray without any symptoms. A chest computed tomography (CT) revealed growing pulmonary nodule in the right lower lobe. Benign lung tumor was suspected and the patient underwent right lower lobe partial resection. Pathological examination demonstrated the tumor to be pulmonary papillary adenoma within round atelectasis.

Determinants of recurrent tricuspid regurgitation following tricuspid valve annuloplasty during mitral valve surgery.

BACKGROUND: The purpose of this study was to determine risk predictors for recurrent tricuspid regurgitation (TR) following tricuspid valve annuloplasty during mitral valve surgery. METHODS: Ninety-eight consecutive patients underwent tricuspid valve annuloplasty concomitant with mitral valve repair (71 patients), replacement (16 patients), or other procedures over a 10-year period. Fifty-seven patients underwent surgery with a flexible band and 41 with a rigid ring. RESULTS: Late TR progression (≥2/4) occurred in eight (14.0%) of flexible band patients, and in nine (22.0%) rigid ring patients. Multivariate analysis did not identify the superiority of one annuloplasty device over the other to prevent recurrent TR. Multivariate risk predictors of late TR progression were late atrial fibrillation (hazard ratio [HR]: 3.78; 95% confidence interval [CI]: 1.19-12.0), and recurrent mitral regurgitation; HR; 4.46; 95%CI; 1.52-13.1). Freedom from TR progression at 5 years was 89.2% in atrial fibrillation-free patients compared to 56.8% in those with atrial fibrillation (log-rank, P = 0.018), and 89.8% in mitral regurgitation-free patients compared to 55.3% in those with recurrent mitral regurgitation (log-rank, P = 0.003). CONCLUSIONS: A durable mitral valve repair and preservation of sinus rhythm are the keys to preventing late TR progression.

The impact of global left ventricular afterload on left ventricular reverse remodeling after aortic valve replacement.

BACKGROUND: Conventional indices such as prosthetic valve effective orifice area (EOA) or transvalvular pressure gradients (TPG) may be unreliable in predicting left ventricular (LV) reverse remodeling after aortic valve replacement (AVR). We hypothesized that the global LV afterload, including valvular and arterial impedance, could influence LV reverse remodeling after AVR. METHODS: Twenty-three consecutive aortic-stenosis patients (mean age, 76 ± 6.4 years) underwent isolated AVR using contemporary externally wrapped pericardial valves (19 mm, 10 patients; 21 mm 11; 23 mm, 2). Valvuloarterial impedance (Zva), a marker of global LV afterload, was measured on serial echocardiography in addition to indexed EOA, energy loss index (ELI), mean TPG, and stroke work loss. LV mass regression was used as a parameter of LV reverse remodeling. RESULTS: The Zva significantly decreased after AVR (5.05 ± 1.7 mmHg/mL/m2 , pre-operatively; 3.12 ± 1.0, postoperatively; 3.13 ± 0.89, at last follow-up) in parallel with increased indexed EOA (0.46 ± 0.13 cm2 /m2 ; 1.13 ± 0.24; 0.96 ± 0.19), ELI (0.55 ± 0.21 cm2 /m2 ; 1.74 ± 0.52; 1.47 ± 0.42), and decreased mean TPG (50.2 ± 19.6 mmHg; 11.1 ± 5.4; 14.7 ± 5.8). The stroke work loss also decreased (26.3 ± 8.5 %; 8.65 ± 4.0; 9.36 ± 3.4). The Zva at last follow-up was significantly correlated with LV mass regression (correlation coefficient, r = - 0.48; P = 0.002), and was a significant predictor of LV reverse remodeling on multiple regression analysis (adjusted odds ratio, -0.43; 95% confidence interval, -31.3 to -0.67, P = 0.042), while indexed EOA, ELI, mean TPG, or systemic arterial compliance were not. CONCLUSIONS: The postoperative Zva was significantly associated with LV mass regression after AVR. Maintaining low global LV afterload following AVR may enhance LV reverse remodeling.

Calcified amorphous tumor of the heart in a hemodialysis patient.

We report a case of calcified amorphous tumor (CAT) of the heart in a 60-year-old Japanese man on hemodialysis. Because the masses in the mitral annulus developed during two-year echocardiographic follow-up, he underwent surgical resection with mitral valve replacement. Histological examination showed that the tumor contained multiple calcified nodules, which confirmed the diagnosis of CAT. This case report reinforces the need to deeply and periodically investigate for cardiac involvement of CAT in all patients on hemodialysis.

Efficacy of Tolvaptan on Fluid Management After Cardiovascular Surgery Using Cardiopulmonary Bypass.

OBJECTIVE: To investigate the efficacy of the selective vasopressin V2-receptor antagonist tolvaptan in postoperative fluid management after cardiovascular surgery using cardiopulmonary bypass. DESIGN: A retrospective cohort study. SETTING: A tertiary care center. PARTICIPANTS: The study comprised 99 patients undergoing cardiovascular surgery using cardiopulmonary bypass. INTERVENTIONS: Oral tolvaptan was administered after surgery. MEASUREMENTS AND MAIN RESULTS: Fifty-one patients treated with tolvaptan were compared with 48 patients treated with intravenous diuretics. Urine volume, the time interval until the patients' body weight returned to the preoperative value, and the length of oxygen dependency after extubation were assessed as surrogate markers for resolution of fluid overload. Urine output on postoperative days 1 and 2 was significantly higher in the tolvaptan-treated patients (29.2 v 20.1 mL/kg/day, p = 0.001; 43.0 v 27.4 mL/kg/day, p<0.001, respectively). Postoperative body weight returned to baseline in 49 tolvaptan-treated patients compared with 33 patients treated with intravenous diuretics (96.1% v 68.8%, p<0.001). Among those with successful body weight reduction, the time interval was shorter in the tolvaptan-treated patients (5 v 7 days, p = 0.006). The length of oxygen dependency after extubation also was shorter in the tolvaptan-treated patients (2 v 3 days, p = 0.006). The urine osmolarity reduction rate before and 4 hours after the first dose of tolvaptan emerged as a significant predictor of its efficacy with a cutoff point of 33.7%, sensitivity of 0.73, and specificity of 0.67 (p = 0.030). CONCLUSION: Tolvaptan facilitated early improvement of postoperative fluid overload after cardiovascular surgery.

Macitentan reverses early obstructive pulmonary vasculopathy in rats: early intervention in overcoming the survivin-mediated resistance to apoptosis.

It remains unknown whether current disease-targeting therapy can histologically reverse obstructive pulmonary vasculopathy and how the timing of the therapy influences the antiremodeling effects of the compound. We test the hypothesis that a novel endothelin receptor antagonist macitentan reverses the early and/or late stages of occlusive pulmonary vascular disease (PVD) in rats. Rats with pulmonary arterial hypertension (PAH), which were produced by combined exposure to a vascular endothelial growth factor receptor inhibitor Sugen 5416 and hypobaric hypoxia for 3 wk, were assigned to receive macitentan or vehicle during 3-5 wk (early study) or during 5-8 wk (late study) after Sugen injection. Compared with vehicle-treated PAH rats and PAH rats evaluated before treatment initiation, the macitentan-treated rats showed decreases in the proportion of occlusive lesions in the early study, a finding consistent with the reversal of right ventricular systolic pressure and indexes of right ventricular hypertrophy and medial wall thickness. Macitentan ameliorated but did not reverse the proportion of occlusive lesions in the late study. Although macitentan decreased the proportion of Ki67+ lesions in both studies, macitentan increased the proportion of cleaved caspase 3+ lesions and suppressed an antiapoptotic molecule survivin expression in the early study but not in the late study. In conclusion, macitentan reversed early but not late obstructive PVD in rats. This reversal was associated with the suppression of survivin-related resistance to apoptosis and proliferation of cells in PVD.

[Transposition of Great Artery].

Transposition of the great artery is one of common congenital cardiac disease resulting cyanosis. Death occurs easily in untreated patients with transposition and intact ventricular septal defect (VSD) in infancy at a few days of age when posterior descending coronary artery (PDA) closed. Since there are 2 parallel circulations, flow from pulmonary to systemic circulation is necessary for systemic oxygenation, and Balloon atrial septostomy or prostaglandin infusion should be performed especially if patient do not have VSD. Although the advent of fetal echocardiography, it is difficult to diagnose the transposition of the great arteries (TGA) as abnormality of great vessels is relatively undistinguishable. The diagnosis of transposition is in itself an indication for surgery, and arterial switch procedure is performed in the case the left ventricle pressure remains more than 2/3 of systemic pressure. Preoperative diagnosis is important as associated anomalies and coronary artery branching patterns are important to decide the operative indication and timing of surgery.

Evaluating Factor VIII Concentrates Using Clot Waveform Analysis.

Background/Objectives: FVIII reagent activity varies across different assays, as well as activated partial thromboplastin time (APTT) reagents. The hemostatic ability of various FVIII reagents was examined via clot waveform analysis (CWA). Methods: APTT was measured using 12 APTT reagents, a small amount of tissue factor-induced FIX activation (sTF/FIXa) and a small amount of thrombin time (sTT) in order to examine 10 FVIII reagents and reference plasma (RP) using CWA. FVIII activity was measured using CWA-APTT, a chromogenic assay, or CWA-sTT. Results: Although the peak time (PT) and peak height (PH) of the CWA-APTT were markedly different in different FVIII reagents using several APTT reagents, the PTs of CWA-APTT were generally normal or shortened and the PHs of CWA-APTT were generally lower than those of RP. The FVIII activity varied, as evaluated using APTT, and was higher when using the CWA-sTT method than the APTT or chromogenic methods. CWA-sTT showed an elevated second peak of first DPH in all FVIII reagents, and both CWA-sTF/FIXa and CWA-sTT were enhanced using APTT reagents. Conclusions: Our evaluation of the hemostatic ability of FVIII reagents varied among APTT reagents. CWA-sTT can be used to further evaluate the hemostatic ability of an FVIII concentrate based on thrombin burst.

Detection of a Prethrombotic State in Patients with Hepatocellular Carcinoma, Using a Clot Waveform Analysis.

Background: Although hepatocellular carcinoma (HCC) is frequently associated with thrombosis, it is also associated with liver cirrhosis (LC) which causes hemostatic abnormalities. Therefore, hemostatic abnormalities in patients with HCC were examined using a clot waveform analysis (CWA). Methods: Hemostatic abnormalities in 88 samples from HCC patients, 48 samples from LC patients and 153 samples from patients with chronic liver diseases (CH) were examined using a CWA-activated partial thromboplastin time (APTT) and small amount of tissue factor induced FIX activation (sTF/FIXa) assay. Results: There were no significant differences in the peak time on CWA-APTT among HCC, LC, and CH, and the peak heights of CWA-APTT were significantly higher in HCC and CH than in HVs and LC. The peak heights of the CWA-sTF/FIXa were significantly higher in HCC than in LC. The peak times of the CWA-APTT were significantly longer in stages B, C, and D than in stage A or cases of response. In the receiver operating characteristic (ROC) curve, the fibrin formation height (FFH) of the CWA-APTT and CWA-sTF/FIXa showed the highest diagnostic ability for HCC and LC, respectively. Thrombosis was observed in 13 HCC patients, and arterial thrombosis and portal vein thrombosis were frequently associated with HCC without LC and HCC with LC, respectively. In ROC, the peak time×peak height of the first derivative on the CWA-sTF/FIXa showed the highest diagnostic ability for thrombosis. Conclusion: The CWA-APTT and CWA-sTF/FIXa can increase the evaluability of HCC including the association with LC and thrombotic complications.

Super Formula for Soluble C-Type Lectin-Like Receptor 2 × D-Dimer in Patients With Acute Cerebral Infarction.

Acute cerebral infarction (ACI) includes atherosclerotic and cardiogenic ACI and involves a thrombotic state, requiring antithrombotic treatment. However, the thrombotic state in ACI cannot be evaluated using routine hemostatic examinations. Plasma soluble C-type lectin-like receptor 2 (sCLEC-2) and D-dimer levels were measured in patients with ACI. Plasma sCLEC-2 and D-dimer levels were significantly higher in patients with ACI than in those without it. The sCLEC-2 × D-dimer formula was significantly higher in patients with ACI than in those without it. A receiver operating characteristic curve showed a high sensitivity, area under the curve, and odds for diagnosing ACI in the sCLEC-2 × D-dimer formula. Although the sCLEC-2 and D-dimer levels were useful for the differential diagnosis between cardiogenic and atherosclerotic ACI, the sCLEC-2 × D-dimer formula was not useful. sCLEC2 and D-dimer levels are useful for the diagnosis of ACI and the sCLEC2 × D-dimer formula can enhance the diagnostic ability of ACI, and sCLEC2 and D-dimer levels may be useful for differentiating between atherosclerotic and cardioembolic ACI.

Three-dimensional computed tomography angiography for the preoperative evaluation of coronary artery disease in lung cancer patients.

BACKGROUND: The number of elderly patients undergoing surgery for lung cancer is increasing. In this study, we assessed the usefulness of three-dimensional computed tomographicangiography (3D-CTA) for the detection of coronary disease in the elderly before surgical intervention for lung cancer. METHODS: One hundred twenty patients admitted to our institution for lung cancer resection were enrolled in the study. 3D-CTA was performed in all 120 patients. RESULTS: Seventy-one patients had normal findings, and forty-nine patients showed coronary stenosis on 3D-CTA examination. Among the latter 49 patients, 24 with slight stenosis underwent lung tumor resection, 23 had coronary angiography for severe stenosis before lung surgery and 2 were not eligible for lung resection because of very severe coronary stenosis. The diagnostic value of 3D-CTA was better than conventional CT. CONCLUSIONS: This study suggests the usefulness of 3D-CTA for the preoperative diagnosis of coronary ischemic disease in elderly lung cancer patients.

[Outcome for pulmonary metastases from malignant osteogenic and soft tissue sarcomas].

We reviewed outcome for pulmonary metastases from malignant osteogenic and soft tissue sarcomas. From January 2001 to December 2010, 43 patients with pulmonary metastases from malignant osteogenic and soft tissue sarcomas were treated. Twenty-four were male and 19 were female. Age ranged 12~86 (median 47.3) years. Operations were performed in 12 cases (group O), radiofrequency ablations were performed in 16 cases (group R), and both were performed in 13 cases (group OR). Overall 5-year survival rate was 24.5%. The 5-year survival was 50.2% for patients with a disease-free interval of more than 12 months and 6.1% for those with a disease-free interval of less than 12 months. There was significant difference in cases of bilateral pulmonary metastases between the group O and the other 2 groups. There was significant difference in the numbers of treated lesions between the group OR and the other 2 groups. There was no difference in overall survival among the 3 groups. These results might suggest that the hybrid therapy of operation and radiofrequency ablation improves the prognosis of patients with pulmonary metastases from malignant osteogenic and soft tissue sarcomas.

Reply to Ishikura, H. What Does Soluble C-Type Lectin-like Receptor 2 (sCLEC-2) × D-Dimer/Platelet (PLT) (sCLEC-2 × D-Dimer/PLT) Mean for Coagulation/Fibrinolysis Conditions? Comment on "Yamamoto et al. Super Formula for Diagnosing Disseminated Intravascular Coagulation Using Soluble C-Type Lectin-like Receptor 2. Diagnostics 2023, 13, 2299".

We would like to thank Dr. Ishikura for his kind comment [...].

Clot Waveform Analysis for Hemostatic Abnormalities.

Clot waveform analysis (CWA) observes changes in transparency in a plasma sample based on clotting tests such as activated partial thromboplastin time (APTT), prothrombin time (PT), and thrombin time (TT). Evidence indicates that not only an abnormal waveform but also peak times and heights in derivative curves of CWA are useful for the evaluation of hemostatic abnormalities. Modified CWA, including the PT with APTT reagent, dilute PT (small amount of tissue factor [TF]-induced clotting factor IX [FIX] activation; sTF/FIXa), and dilute TT, has been proposed to evaluate physiological or pathological hemostasis. We review routine and modified CWA and their clinical applications. In CWA-sTF/FIXa, elevated peak heights indicate hypercoagulability in patients with cancer or thrombosis, whereas prolonged peak times indicate hypocoagulability in several conditions, including clotting factor deficiency and thrombocytopenia. CWA-dilute TT reflects the thrombin burst, whereas clot-fibrinolysis waveform analysis reflects both hemostasis and fibrinolysis. The relevance and usefulness of CWA-APTT and modified CWA should be further investigated in various diseases.