Long-Term Outcomes of Coronary Artery Bypass Grafting Using an Internal Thoracic Artery versus a Radial Artery as a Second Arterial Graft

PURPOSE

To compare the outcomes of left circumflex artery (LCx) revascularization using an internal thoracic artery (ITA) or radial artery (RA) as the second arterial graft.

METHODS

Patients who underwent primary isolated coronary artery bypass grafting with left anterior descending artery revascularization using an ITA and LCx revascularization using another bilateral ITA (BITA group) or an RA (ITA-RA group) were included. All-cause mortality (primary endpoint), cardiac death, major adverse cardiac events, in-hospital death, and deep sternal wound infection (secondary endpoints) were evaluated.

RESULTS

Among 790 patients (BITA, n = 548 (69%); ITA-RA, n = 242 (31%)), no significant difference in all-cause mortality between the groups was observed (hazard ratio (HR): 0.87; 95% confidence interval (CI): 0.67-1.12; p = 0.27) during follow-up (mean, 10 years). Multivariate analysis revealed that the BITA group exhibited significantly lower rates of long-term all-cause mortality (HR: 0.63; 95% CI: 0.48-0.84; p = 0.01). In the propensity-matched cohort (n = 480, 240 pairs), significantly fewer all-cause deaths occurred in the BITA group (HR: 0.66; 95% CI 0.47-0.93; p = 0.02). There were no significant differences in secondary outcomes.

CONCLUSIONS

When used as second grafts for LCx revascularization, ITA grafts may surpass RA grafts in reducing all-cause mortality 10 years postoperatively.

Sternal closure with sandwiched three-piece bioresorbable mesh reduces postoperative hemorrhage: a retrospective study

BACKGROUND

Median sternotomy is the most performed procedure in cardiac surgery; however, sternal displacement and bleeding remains a problem. This study aimed to investigate whether sternal reconstruction using a sandwiched three-piece bioresorbable mesh plate can prevent postoperative sternal displacement and bleeding more than a bioresorbable pin.

METHODS

Patients (n = 218) who underwent median sternotomy were classified according to whether a sandwiched three-piece bioresorbable mesh plate and wire cerclage (group M, n = 109) or a bioresorbable pin and wire cerclage (group P, n = 109) were used during sternal reconstruction. The causes of postoperative sternal displacement and bleeding with computed tomography data were analyzed and compared between the groups.

RESULTS

The preoperative patient characteristics did not significantly differ between the groups. However, the evaluation of sternal and substernal hematoma on postoperative day 5 using computed tomography showed sternal displacement in 4 (4%) and 22 (20%) patients, and substernal hematoma in 17 (16%) and 41 (38%) patients in groups M and P, respectively; this difference was significant. Furthermore, the amount of bleeding at 6 h postoperatively was lower in group M than in group P (235 ± 147 vs. 284 ± 175 mL, p = 0.0275). Chest reopening, intubation time, and length of intensive care unit and hospital stays did not differ between the groups. The evaluation of substernal hematoma based on computed tomography yielded a significantly lower for group M than for group P, revealing that the mesh plate was an independent predictor of substernal hematoma prevention.

CONCLUSION

Sternal fixation with a three-piece bioresorbable mesh plate could prevent postoperative sternal displacement, bleeding, and substernal hematoma more than sternal fixation with a pin.

Use of Renal Near-Infrared Spectroscopy and Urinary Neutrophil Gelatinase-Associated Lipocalin Monitoring as Indicators of Acute Kidney Injury in Pediatric Cardiac Surgery

Acute kidney injury (AKI) is a common complication following cardiac surgery under cardiopulmonary bypass (CPB) in children. A prospective study for examining urinary neutrophil gelatinase-associated lipocalin (NGAL) and renal near-infrared spectroscopy (NIRS) trends during AKI was conducted among pediatric patients undergoing cardiac surgery with CPB. Urinary NGAL showed a significant difference between intensive care unit admission (0 h) and 2 h post-admission (p < 0.001) and remained significant up to 4 h (p < 0.05). The renal NIRS in the AKI group showed a significant rate of decrease and lower values during the intraoperative period (p < 0.05). The cumulative median saturation of renal regional saturation of oxygen (rSO2) during CPB was 1637.5% min in the AKI group and 943.0% min in the non-AKI group. The median renal rSO2 scores at a reduction of 20% and 25% were significantly higher (p < 0.001) in the AKI group. Our results suggest that monitoring renal rSO2 scores and limiting their decline might be useful in preventing AKI. The combination of NGAL, renal rSO2, and renal rSO2 scores might be useful in the early diagnosis of AKI during pediatric cardiac surgery.

Management of cardiovascular surgery in patients with systemic lupus erythematosus including thromboembolism and multiple organ failure prevention: A retrospective observational study

Systemic lupus erythematosus is a chronic autoimmune disease that affects most tissues. Cardiovascular events are critical, life-threatening, long-term complications of systemic lupus erythematosus (SLE). We report our single-center experience of performing cardiovascular surgery in patients with SLE while avoiding postoperative complications. We also suggest a new approach for cardiopulmonary bypass and perioperative management. We applied the antiphospholipid antibody syndrome (APS) severity classification published by the Japan Intractable Disease Information Center to patients with SLE for perioperative management. Patients with Grade III or higher severity are treated with a slightly relaxed version of catastrophic APS therapy. This treatment modality includes glucocorticoids, anticoagulation, intravenous immunoglobulin, and plasma exchange. Between April 2010 and January 2021, 26 patients (2 males, 24 females) with SLE underwent cardiovascular surgery. The mean age was 74.2 ± 13.0 years (38-84 years). The primary outcomes were in-hospital mortality and long-term results, and the secondary outcomes were related to bleeding/embolization and coagulation function/platelet count. A subset analysis was performed to examine treatment efficacy in the APS Grade III or higher group. Of the 26 patients, 17 underwent valve surgery, 4 underwent isolated coronary artery bypass grafting, and 5 underwent thoracic aortic aneurysm surgery. There were no in-hospital deaths or associated bleeding/embolic complications. Postoperative antithrombin III decreased in patients who underwent valvular and aortic surgery, and platelet counts recovered to preoperative levels within 7 to 10 days. The 5- and 10-year survival rates were 80.5% and 53.7%, respectively. In addition, there were 10 patients with APS Grade III or higher, but there was no significant difference in the frequency of complications other than platelet recovery after treatment. The surgical outcome of open-heart surgery in patients with SLE was good. Surgical treatment of cardiovascular disease in these patients is difficult and complex. We focused on blood coagulation abnormalities and treated each patient by selecting the best individual treatment protocol according to the severity of the disease, taking into account the risk of bleeding and thrombosis. Management of blood coagulation function in these patients is essential, and careful therapeutic management should be considered during open-heart surgery.

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.

Oxygen delivery-guided perfusion for the prevention of acute kidney injury: A randomized controlled trial

OBJECTIVES

The reduction of postoperative acute kidney injury in patients undergoing cardiopulmonary bypass surgery using an oxygen delivery-guided perfusion strategy (oxygen delivery strategy) for cardiopulmonary bypass management compared with a fixed flow perfusion (conventional strategy) remains controversial. The purpose of this study was to determine whether a oxygen delivery strategy would reduce the incidence of postoperative acute kidney injury in patients undergoing cardiopulmonary bypass surgery.

METHODS

We randomly enrolled 300 patients undergoing cardiopulmonary bypass surgery. Patients were randomly assigned to a oxygen delivery strategy (maintaining a oxygen delivery index value >300 mL/min/m² through pump flow adjustments during cardiopulmonary bypass) or a conventional strategy (a target pump flow was determined on the basis of the body surface area). The primary end point was the development of acute kidney injury. Secondary end points were the red blood cell transfusion rate and number of red blood cell units, intubation time, postoperative length of stay in the intensive care unit and the hospital, predischarge estimated glomerular filtration rate, and hospital mortality.

RESULTS

Acute kidney injury occurred in 20 patients (14.6%) receiving the oxygen delivery strategy and in 42 patients (30.4%) receiving the conventional strategy (relative risk, 0.48; 95% confidence interval, 0.30-0.77; P = .002). The secondary end points were not significantly different between strategies. In a prespecified subgroup analysis of patients who had nadir hematocrit less than 23% or body surface area less than 1.40 m², the oxygen delivery strategy seemed to be superior to the conventional strategy and the existence of quantitative interactions was suggested.

CONCLUSIONS

An oxygen delivery strategy for cardiopulmonary bypass management was superior to a conventional strategy with respect to preventing the development of acute kidney injury.

Risk factors for postoperative delirium on oxygen delivery-guided perfusion

Background

Studies have demonstrated the efficacy of oxygen delivery-guided perfusion (ODGP) in preventing postoperative acute kidney injury, but the benefit of ODGP for delirium has not been confirmed. We retrospectively investigated the risk factors for postoperative delirium in patients who underwent ODGP (with oxygen delivery index [DO2i] > 300 mL/min/m2).

Methods

Consecutive patients who underwent on-pump cardiovascular surgery with ODGP from January 2018 to December 2020 were retrospectively analyzed. In addition to examining patients’ DO2i during cardiopulmonary bypass (CPB), we quantified the two primary DO2 components-hematocrit (Hct) and pump flow. Delirium was defined based on the Intensive Care Delirium Screening Checklist (ICDSC). Patients were divided into three groups: no delirium (ICDSC score = 0), subsyndromal delirium (ICDSC score = 1–3), and clinical delirium (ICDSC score ≥ 4).

Results

Multivariate analysis identified only the number of red blood cell (RBC) units transfused, intubation time, and the cumulative time below the Hct threshold of 25% as predictive factors of postoperative delirium. Although patients with higher ICDSC scores had greater hemodilution during CPB, ODGP resulted in a higher pump flow, and DO2i was maintained above 300 mL/min/m2, with no significant difference between the three groups.

Conclusions

A low Hct level during CPB with ODGP, the number of RBC units transfused, and intubation time were associated with postoperative delirium. Further investigations are needed to determine the ability of ODGP to prevent low Hct during CPB.

Effects of Phase II Cardiac Rehabilitation on Physical Function and Anxiety Levels in Frail Patients

Background: Frailty is an important prognostic factor in patients with cardiovascular diseases (CVD), and patients with CVD have a high rate of concurrent psycho-emotional stress, as well as depressive mood and anxiety symptoms. Despite this, few reports have examined the effects of the efficacy of Phase II cardiac rehabilitation (CR) in frail patients, including improvements in anxiety levels.

Methods and Results: In all, 137 patients (mean [±SD] age 65.8±13.0 years; 71% male) who participated in Phase II CR and were assessed after CR completion were included in this study. Patients were evaluated using the Kihon Checklist (KCL) form at the beginning of CR and were divided into the 3 groups according to KCL scores: frail (n=34, 25%), pre-frail (n=40, 29%), and non-frail (n=63, 46%). Physical function and anxiety levels were compared among the 3 groups. The pre-frail and frail groups had significantly higher state anxiety and trait anxiety than the non-frail group (P<0.01). At the end of Phase II CR, all 3 groups showed significant improvements in the 6-min walking distance (P<0.05). State anxiety improved significantly in the non-frail and pre-frail groups, whereas trait anxiety only improved in the non-frail group.

Conclusions: Physical function was improved in frail patients who participated in Phase II CR. However, there was no significant improvement in their level of anxiety.

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.

OP0238 CLINICAL ANALYSIS OF 34 CASES OF CARDIAC COMPLICATIONS REQUIRING SURGICAL INTERVENTION IN SYSTEMIC LUPUS ERYTHEMATOSUS AND ASSESSMENT ABOUT MECHANISM OF DEVELOPMENT WITH IMMUNOLOGICAL ANALYSIS

Background

In cases of systematic lupus erythematosus (SLE) that lead to surgery due to the development of heart diseases such as valvular disease, ischemic heart disease and aortic aneurysm, early detection and careful monitoring are important. An absence of background diseases or immunopathological examination of the myocardial tissue in SLE cases with cardiovascular lesions demonstrates the lack of knowledge in this area. In recent years, however, there have been reports of neutrophil extracellular traps being involved in the fulminant onset of SLE.

Objectives

This study aimed to analyze clinically and immunohistopathologically the pathophysiology of heart diseases associated with SLE.

Methods

We performed left atrial appendage resection in 34 patients, including patients with cardiovascular lesions, who underwent heart surgery for SLE complications from 2012 to 2021. Tissue analysis was conducted in 9 cases. The left atrial appendage, in cases of non-collagen valvular disease, was used as the control. Tissue staining of cardiomyocytes was carried out by adding anti-neutrophil extracellular(NE) antibodies(Abs) to anti-human IgG antibody (Ab), anti-IgM Ab and anti-C3 Ab.

Results

Of the 34 SLE patients 14 had valvular disease, 8 had ischemic heart disease and 12 had aneurysms. Preoperative SLE activity was relatively stable with only 1 patient below the CH50 standard and 6 patients above the anti-DNA Ab standard. The Ab positivity rate for the patients in this study was higher than that of the 687 SLE patients who were previously tested in 2019. The presence of anti-CL Abs was 55.6%, which was higher than the 25.5% observed in previous SLE patients. In this study, anti-SS-A and anti-RNP Abs tended to be relatively numerous. An example of immunohistochemical staining of IgG in the left atrial appendage is presented (Figure 1a). IgG deposits were not observed on the left side of the myocardial fibers in the control group, whereas IgG deposits were observed on the right side in the SLE group. Deposits were also observed in tissues that were not located in the affected areas. The presence or absence of tissue deposition in the myocardial fibers and clinical findings in 2 cases of the control group and 9 cases of the SLE complication group are reported in Table 1. IgG deposits were found in the myocardial fibers of 6 of the 9 patients in the SLE complication group, and deposits were found in the left atrial appendage tissue regardless of the type of heart disease, suggesting a potential change in the heart tissue. In the SLE group, 5 cases were positive for antiphospholipid (APS) Abs, while 7 cases were positive for either anti-SS-A or anti-RNP Abs. Only 2 cases had elevated preoperative anti-DNA Ab and complement reduction. Of the SLE complication group, 2 of the 9 cases were negative for all Abs but IgG deposits were observed in a case. Of these 4 cases were selected and stained with anti-IgM, anti-C3 and anti-NE Abs. However IgM and C3 deposits were only observed in one patient who developed myocardial infarction at the age of 39 and was triple positive for APS, anti-SS-A and anti-RNP Abs (Figure 1b). There were also no NE deposits in any of the cases. Even if complement and anti-DNA Ab levels in the serum are normal, attention should be paid to heart disease complications during the long-term observation of SLE patients. In particular, attention should be paid to various autoantibody-positive cases such as APS, anti-SS-A Ab and anti-RNP Ab. The anti-NE Ab was not stained in this study because the tissue was different from the lesion site and because it occurred during the chronic course.

Conclusion

In SLE patients who developed cardiovascular lesions and required surgery, immunological abnormalities may occur in the myocardial tissue even if serum complement and anti-DNA Ab levels are stable.

References

[1]Stephane Zuily et al. Valvular Curr Rheumatol Rep (2013) 15:320.

[2]Zawadowski GM et al. Lupus. 2012;21(13):1378-84.

[3]Daniel Appelgren et al. Autoimmunity 2018,vol51,No.6,310-318.

Disclosure of Interests

None declared

Successful Surgical and Endovascular Multidisciplinary Therapy for Mid-aortic Syndrome with Complicated Atherosclerotic Comorbidities in an Older Patient

Mid-aortic syndrome (MAS) is a rare vascular disorder that causes refractory hypertension. A 76-year-old woman was hospitalized for acute heart failure (HF) with drug-resistant hypertension; other comorbidities included epigastric artery rupture, old myocardial infarction, an intraventricular thrombus, and a cerebral artery aneurysm. Angiography revealed severe narrowing of the descending aorta, which led to the diagnosis of MAS. Although intensive medical treatment improved her HF, optimal blood pressure (BP) could not be achieved. Percutaneous coronary intervention and surgical bypass for diseased aorta was then performed in two stages, resulting in the achievement of optimal BP and alleviation of HF.

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.

Atypical Shone's Complex Diagnosed at 70 Years Old: Presenting with Double-orifice Mitral Valve, Bicuspid Aortic Valve, and Aortic Coarctation

Atypical Shone's complex is a rare congenital anomaly involving a left-sided obstructive lesion of two or three cardiovascular levels. A 70-year-old man with dyspnea on exertion was diagnosed with severe aortic stenosis (AS) with a bicuspid valve, complicated by severe aortic coarctation (CoA) and a double-orifice mitral valve. He underwent surgery for AS and CoA in one session. It is important to search for complicated malformations, even in cases of bicuspid aortic valve found in old age.

Pseudoaneurysm with a fistula to the right ventricle late after surgical repair of type A aortic dissection in a patient with systemic lupus erythematosus

Background

Pseudoaneurysm with a shunt to the right ventricle after aortic repair for acute aortic dissection is an extremely rare and life-threatening condition. Surgical treatment is unavoidable, but surgery is complicated, and there are some pitfalls. This study describes the reoperation performed in a patient at a high surgical risk by clarifying the shunt site using multimodality imaging before surgery.

Case presentation

A 69-year-old woman with a history of systemic lupus erythematosus (SLE) and Sjogren’s syndrome presented with a pseudoaneurysm 1 year after emergency surgery for acute type A aortic dissection. Eight years after the first surgery, she experienced sudden chest pain and presented to the emergency department. Her dyspnea worsened; therefore, echocardiography and three-dimensional computed tomography (3DCT) were performed, and a pseudoaneurysm and shunt to the right ventricle were identified. The medical team attempted to close the shunt with a percutaneous catheter but was unsuccessful, and she was referred to our department for surgical treatment. The pseudoaneurysm originating from the proximal side of the aorta was large (diameter = 55 mm), and echocardiography-gated 3DCT identified the shunt from the pseudoaneurysm to the right ventricle. First, extracorporeal circulation was initiated, and resternotomy was performed. We could not insert the left ventricular venting tube from the right side because of the pseudoaneurysm size. Instead, the tube was inserted from the left atrial appendage. We found a half-circumferential disengaged anastomosis around the proximal anastomosis, which formed the large pseudoaneurysm leading to a fistula in the right ventricle. We closed the fistula and performed a Bentall operation. The patient had a good postoperative course and was discharged on postoperative day 21. She continued treatment for SLE and Sjogren’s syndrome, and her inflammatory reaction improved.

Conclusions

We performed a Bentall operation and fistula closure with resternotomy in a patient with type A aortic dissection with SLE and Sjogren’s syndrome. Multimodal imaging is essential in defining the pseudoaneurysm and the fistula surrounding the anatomy while ensuring their resolution and guiding the approach for operation.

Mycotic Aortic Arch Aneurysm Caused by Clostridium perfringens

We report a case of a 79-year-old man for a mycotic aortic arch aneurysm caused by Clostridium perfringens. The patient who had been hospitalized for cholangitis two months prior revisited the hospital for fever and left precordial pain. He was suspected of an infected aortic aneurysm in the distal arch due to emphysematous changes observed. After antibiotics treatment, the emphysematous changes disappeared. However, he underwent urgent total arch replacement due to a new ulcer-like projection and enlargement of the aortic aneurysm, which were observed at that time. Clostridium-infected infectious aneurysms require not only treatment for vascular lesions but also scrutiny of complications, such as cancer.

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01398-0.

Nutritional supplement drink reduces inflammation and postoperative depression in patients after off-pump coronary artery bypass surgery

BACKGROUND

Coronary artery bypass grafting is a surgical treatment for ischemic heart disease. Although development in surgical technique and improvement of perioperative management reduced the postoperative complications, some patients still delayed in progress of postoperative rehabilitation. In this study, we aimed to investigate the effect of daily intake of an herbal medicine-containing drink for rehabilitation after surgery in patients with ischemic heart disease.

AIM

To investigate the effect of taking an herbal medicine-containing, commercially available drink for postoperative rehabilitation in those patients.

METHODS

Patients who underwent isolated off-pump coronary artery bypass (OPCAB) surgery were divided into two groups depend on the timing of the admission to the hospital: the Yunker (YKR) group, that consumed one bottle of a caffeine-free nutritional supplement drink on a daily basis and the control group (CTL) that underwent regular rehabilitation.

RESULTS

A total of 229 patients (CTL = 130, YKR = 99) were enrolled. No significant differences were observed in the baseline characteristics between the two groups. The YKR group had a significantly increased number of daily steps postoperatively (P < 0.05) and had significantly lower postoperative serum tumor necrosis factor-alpha levels (P < 0.01), while no significant differences were observed in the levels of other inflammatory or stress-related cytokines (interleukin-6, adiponectin, superoxide dismutase, and urine 8-hydroxy-2′-deoxyguanosine) between the two groups. Also, the YKR group showed a significant improvement in the Hospital Anxiety and Depression Score (P < 0.05). Moreover, there were no differences in postoperative complications and the duration of postoperative hospital stay between the two groups.

CONCLUSION

Our results demonstrated that the daily intake of an herbal medicine-containing drink after OPCAB surgery may have beneficial effects on cardiac rehabilitation by reducing inflammation markers and depression.

Surgical 5-year Outcomes of Extra-Anatomical Bypass for Middle Aortic Syndrome: A Case Series

BACKGROUND

Middle aortic syndrome is a rare disease. Several surgical treatments are available; however, the optimal treatment strategy and long-term outcomes remain unelucidated. We herein report the 5-year outcomes of six patients treated with extra-anatomical bypass surgery for middle aortic syndrome.

CASE PRESENTATIONS

Between 2013 and 2016, six patients underwent extra-anatomical bypass for middle aortic syndrome at our institute: three had Takayasu's arteritis, one had vessel vasculitis, and two had middle aortic hypoplastic syndrome of unknown origin. The patients included five women and one man, with a mean age of 59.7 years. Four patients had uncontrolled hypertension and were receiving antihypertensive medications. The mean ankle-brachial pressure index was .61. The three patients with Takayasu's arteritis were hospitalized for congestive heart failure. These patients underwent bypass surgery from the descending aorta to the infrarenal abdominal aorta, and one also underwent concomitant heart surgery. The patient with microscopic polyangiitis underwent Y-grafting with an aortic aneurysmectomy. Subsequently, bypass surgery was performed from the descending aorta to the graft via the diaphragm. The two patients with unknown causes underwent bypass surgery from the proximal descending aorta to the distal descending thoracic aorta. There were no early or late deaths at the 5-year follow-up. We did not observe any changes in anastomotic site stenosis or new aneurysmal changes during the follow-up period. The number of antihypertensive medications was reduced in all cases, and critical symptoms, including headache, severe abdominal pain, claudication, and heart failure, improved in all patients. The ankle-brachial pressure index increased to 1.11 and did not change for five years. Renal function remained stable, and the brain natriuretic peptide level decreased from 302.8 to 74.5 pg/mL at follow-up.

CONCLUSION

Extra-anatomical bypass for middle aortic syndrome is safe and effective, and can help prevent renal failure, and relieve critical ischemic symptoms.

Evidence and Challenges in Left Atrial Appendage Management

This review aimed to discuss the anatomical properties of the left atrial appendage (LAA), its relationship with atrial fibrillation (AF), effectiveness of LAA occlusion (LAAO), techniques, and new devices used to perform this procedure. An electronic search was performed to identify studies, in the English language, on LAA management. Searches were performed on PubMed Central, Scopus, and Medline from the dates of database inception to February 2020. For the assessed papers, data were extracted from the reviewed text, tables, and figures, by two independent authors. Anticoagulant therapy for patients with AF has proven beneficial and is highly recommended, but it is challenging for many patients to maintain optimal treatment. Surgery is the most cost-effective option; surgical methods include simple LAA resection, thoracoscopic surgery, and catheter treatment. Each procedure has its advantages and disadvantages, and many prospective studies have been conducted to evaluate various treatment methods. In managing the LAA, dissection of the LAA, such as changes in its shape and size due to remodeling during AF, changes in autonomic nerve function, and thrombosis, must be understood anatomically and physiologically. We believe that early treatment intervention for the LAA should be considered particularly in cases of recurrent AF.

Conclusion: SLET under artificial pneumothorax is feasible and safe in minimally invasive McKeown esophagectomy.

Atrial septal defect and patent ductus arteriosus closure in an 8-month-old patient with Silver-Russell syndrome

We present a case of an 8-month-old boy with Silver-Russell syndrome who had high pulmonary vascular resistance, atrial septal defect, and patent ductus arteriosus. He underwent cardiac surgery using cardiopulmonary bypass without any complications.

Association of phase angle with hospital-acquired functional decline in older patients undergoing cardiovascular surgery

OBJECTIVE

The aim of this study was to examine whether preoperative phase angle (PhA) measured by bioelectrical impedance analysis was associated with a hospital-acquired functional decline in older patients undergoing cardiovascular surgery.

METHODS

This was an observational study of prospectively collected data of 114 patients (>65 y of age) with cardiovascular disease who underwent elective cardiovascular surgery between September 2019 and August 2020. Patients were classified into tertiles based on PhA levels. Factors associated with the occurrence of hospital-acquired functional decline (postoperative recovery to preoperative physical function was not possible) were analyzed using univariate and multivariate analyses.

RESULTS

Patients in the low PhA group were significantly older than those in the middle and high PhA groups; were predominantly women; had higher New York Heart Association cardiovascular and EuroSCORE severity scores; and had significantly lower levels of body mass index, Geriatric Nutritional Risk Index, hemoglobin, and albumin. There was a significant correlation between PhA and nutrition and physical function. The incidence of hospital-acquired functional decline occurred in 26.3% of all patients, with a significantly higher incidence in patients in the low PhA group. Multivariate analysis showed that PhA was extracted as a factor for the hospital-acquired functional decline in all the models.

CONCLUSIONS

PhA was associated with hospital-acquired functional decline in older patients undergoing cardiovascular surgery. PhA is likely to be a comprehensive indicator of physical health that indicates nutritional status, physical function, and geriatric syndrome (frailty/sarcopenia), and is an important predictor of hospital-acquired functional decline in this group of older patients.

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.

Small saccular aneurysms in the coronary and right epigastric arteries: A case report

Small saccular aneurysm in the right gastroepiploic artery is a sporadic disease accounting for approximately 0.4% of abdominal visceral aneurysms rarely observed during routine examination of other illnesses; however, it has been reported following rupture. The right gastroepiploic artery is a common alternative to the internal thoracic artery in coronary artery bypass grafting. We report a case of small aneurysms in the left anterior descending artery, diagonal branch artery, and right gastroepiploic artery and a pseudoaneurysm in right gastroepiploic artery. Coronary artery bypass grafting was performed using the left internal thoracic artery and right gastroepiploic artery, and a 5-mm aneurysm was observed in the right gastroepiploic artery. The resected 5-mm right gastroepiploic artery aneurysm was saccular. Pathological investigation revealed media loss and adventitial thinning, indicating the possibility of an aneurysm rupture. Thus, preoperative three-dimensional computed tomography is beneficial for patients with coronary arterial aneurysms and preoperative evaluation of right gastroepiploic artery to help achieve good clinical outcomes in patients undergoing coronary artery bypass grafting with another arterial aneurysm.

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.

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.

Association Between Constipation and Frailty Components in Patients Undergoing Late Phase II Cardiac Rehabilitation

Background

The Japanese Ministry of Health, Labour and Welfare reported that the overall constipation complaint rates among men and women are 2.5% and 4.6%, respectively. To evaluate the impact of constipation on patients with cardiovascular diseases, we investigated the association between constipation and frailty components in patients undergoing cardiac rehabilitation (CR).

Methods

We enrolled 102 consecutive patients undergoing late phase II CR (mean age: 62.7 ± 13.4 years; 68 (67%) were men). We investigated clinical characteristics, observed defecation status and evaluated frailty components assessed by the Kihon checklist. According to the Clinical Guidelines for Chronic Constipation, the subjects were divided into constipation and non-constipation groups.

Results

Constipation was noted in 33 patients (32%). Interestingly, the constipation complaint rate was only 15%. Age was significantly higher in the constipation group than in the non-constipation group; however, no differences in sex, underlying diseases and prevalence rates of coronary risk factors were observed between the two groups. Body mass index, hemoglobin level, albumin level and estimated glomerular filtration rate were significantly lower in the constipation group than in the non-constipation group. The prevalence of frailty was significantly higher in the constipation group than in the non-constipation group. Physical ability, seclusion and depression scores were significantly higher in the constipation group than the non-constipation group.

Conclusions

Constipation was associated with physical function and depression score as components of frailty in patients undergoing CR.

Sesame lignans suppress age-related disorders of the kidney in mice

OBJECTIVE

Sesamin is a functional ingredient in sesame (Sesamum indicum) seeds and has many physiological effects. This study investigated whether sesame lignans, sesamin and episesamin (1:1), can suppress age-related disorders of the kidney.

MATERIALS AND METHODS

Twenty-month-old mice were divided into three groups, and each group received a regular diet (O-C), diet containing sesame lignans (O-SE), and diet containing sesame lignans and α-tocopherol (VE; O-SE+VE), respectively, for 5 months. Six-month-old young mice (Y-C) were compared to the older mice.

RESULTS

Renal lipofuscin deposition was increased in the O-C group compared to that in the Y-C group and its deposition with aging was significantly decreased in both O-SE and O-SE+VE groups. Plasma blood urea nitrogen levels in the O-C group increased compared to those in the Y-C group; however, those in both O-SE and O-SE+VE groups did not differ from those in the Y-C group. The number of podocytes in the O-C group decreased compared to that in the Y-C group and this effect was attenuated in the O-SE and O-SE+VE groups. The effect was strongest in the O-SE+VE group. Histological examinations showed that glomerular hypertrophy accompanied by mesangial hyperplasia and renal tubular degeneration was less severe in the O-SE and O-SE+VE groups than in the O-C group. Moreover, age-related increases in the mRNA expression of NADPH oxidase- and inflammation-related genes, including p67phox, p40phox, TNFα, and IL-6, in the kidney were suppressed in the O-SE and O-SE+VE groups.

CONCLUSIONS

Sesame lignans might be useful to suppress age-related kidney disorders, and these effects could be enhanced with VE.

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.

Prognostic impact of peak oxygen uptake and heart rate reserve in patients after off-pump coronary artery bypass grafting

BACKGROUND

Peak oxygen uptake (peak VO₂ ) and heart rate reserve (HRR) are independent prognostic markers of cardiovascular disease. However, the impact of peak VO₂ and HRR on long-term prognosis after off-pump coronary artery bypass grafting (OP-CABG) remains unclear.

HYPOTHESIS

To determine the prognostic impact of peak VO₂ and HRR in patients after OP-CABG.

RESULTS

We enrolled 327 patients (mean age, 65.1 ± 9.3 years; male, 80%) who underwent OP-CABG and participated in early phase II cardiac rehabilitation. All participants underwent cardiopulmonary exercise testing (CPET) at the beginning of such rehabilitation. Overall, 48 (14.6%) patients died during the median follow-up period of 103 months. The non-survivor had significantly lower levels of peak VO₂ (10.6 ± 0.5 vs. 13.7 ± 0.2 ml/kg/min, p < .01) and HRR (24.2 ± 1.8 vs. 32.7 ± 0.8 beats/min, p < .01) than the survivor. In both groups, peak VO₂ significantly correlated with HRR (p < .01). Moreover, patients were divided into four groups according to the peak VO₂ and HRR levels for predicting total mortality. The low-peak VO₂ /low-HRR group had a significantly higher mortality risk than the other groups (hazards ratio, 5.61; 95% confidence interval, 2.59-12.16; p < .01). After adjusted the confounding factors, peak VO₂ and HRR were independently associated with total mortality (both p < .05).

CONCLUSIONS

HRR is a simple parameter of CPET and an important prognostic marker for the risk stratification of total mortality even in patients with low-peak VO₂ after OP-CABG.

Simultaneous Estimation of Gender Male and Atrial Fibrillation as Risk Factors for Adverse Outcomes Following Transcatheter Aortic Valve Implantation

Accurate outcome prediction following transcatheter aortic valve implantation (TAVI) has gained further importance along with expanding its indication to patients with a lower surgical risk. Although previous studies have evaluated the prognostic impacts of gender and atrial fibrillation (AF) in TAVI patients, these two factors have rarely been addressed simultaneously. This retrospective observational study based on a multicenter TAVI registry involved 1088 patients who underwent TAVI between May, 2010 and February, 2020 at 3 hospitals in Japan. Participants were divided into 4 groups by gender and pre-existing AF, such as Female AF(-) (n = 559), Male AF(-) (n = 266), Female AF(+) (n = 187) and Male AF(+) (n = 76). Primary and secondary endpoints were death due to any and cardiovascular cause, and the composite of all-cause death and heart failure hospitalization, respectively. The median follow-up period was 538 days. Cumulative incidences of primary and secondary endpoints were lower in the Female AF(-) group compared to the other 3 groups. Adjusted multivariate Cox proportional hazard analyses showed an independent association of either or both of male gender and AF with adverse outcomes, when compared to the group with none of these (hazard ratios and 95% confidence intervals vs. Female AF(-) (reference) for all-cause death of Male AF(-): 2.7, 1.6-4.6, p < 0.001, Female AF(+): 3.5, 2.1-6.0, p < 0.001, and Male AF(+): 3.9, 1.9-7.8, p < 0.001), while there was no evidence of their synergistic prognostic impact. Male gender and being complicated by AF independently, but not synergistically, predicted poor long-term outcomes in patients undergoing TAVI.

Relationship Between Kihon Checklist Score and Anxiety Levels in Elderly Patients Undergoing Early Phase II Cardiac Rehabilitation

Background

The frailty state consists of not only physical but also psycho-emotional problems, such as cognitive dysfunction and depression as well as social problems. However, few reports have examined the relationship between frailty and anxiety levels in elderly patients undergoing cardiac rehabilitation (CR).

Methods

We analyzed 255 patients (mean age: 74.9 ± 5.8 years, 67% male) who participated in early phase II CR at Juntendo University Hospital. At the beginning of CR, patients carried out self-assessments based on the Kihon Checklist (KCL) and the State Trait Anxiety Inventory Form (STAI). Patients were divided into three groups: frailty group (n = 99, 39%), pre-frailty group (n = 81, 32%), and non-frailty group (n = 75, 29%) according to the KCL. We assessed results from the KCL scores and its relationship with anxiety levels.

Results

Among the three groups, there were no significant differences in age, underlying illnesses, or the prevalence of coronary risk factors. Depressive mood domains of the KCL were significantly higher in the frailty and pre-frailty groups than in the non-frailty groups (3.0 ± 1.5 vs. 1.4 ± 1.2 vs. 0.4 ± 0.6; P < 0.01). The state anxiety level was significantly higher in the frailty group than in the non-frailty group (41.6 ± 0.9 vs. 34.9 ± 1.0; P < 0.01). The trait anxiety levels were significantly higher in the frailty group and pre-frailty group than in the non-frailty group (45.5 ± 0.9 vs. 39.2 ± 1.0 vs. 35.1 ± 1.1; P < 0.01). State anxiety and trait anxiety also showed a significantly positive correlations with the KCL scores (r = 0.32 vs. 0.41, P < 0.01).

Conclusions

Frailty scores were positively correlated not only with physical function but also with depression mood and anxiety levels in elderly patients undergoing early phase II CR. These results suggest that assessment of depressive mood and anxiety is also important in elderly patients undergoing early phase II CR.

Surgical Treatment of Celiacomesenteric Trunk Aneurysm: Report of 2 Cases

BACKGROUND Celiac artery aneurysm is very rare, and even is more uncommon in patients with celiacomesenteric trunks. With recent developments in diagnostic imaging, the detection of asymptomatic abdominal visceral aneurysms has increased. However, some abdominal visceral aneurysms are still first discovered after a rupture. An abdominal visceral aneurysm rupture can occur suddenly and lead to shock due to intraperitoneal hemorrhage. Two cases of celiac artery aneurysms that involved common celiacomesenteric trunks are presented. CASE REPORT Case 1 was a 63-year-old man who was referred to our facility for further study after a routine abdominal ultrasound identified an aneurysm in the superior mesenteric artery. Contrast-enhanced computed tomography (CT) scan revealed a 39-mm aneurysm in the celiacomesenteric trunk and its branches. Case 2 was a 32-year-old man who was referred to our facility after an abdominal ultrasound performed during a physical examination revealed a celiac artery aneurysm. Contrast-enhanced CT revealed a 31-mm aneurysm in the celiacomesenteric trunk and its branches. In both patients, the aneurysms were proximally located, and the distinctive anatomy of the celiacomesenteric trunk made endovascular treatment difficult. Open replacement and reconstructive surgery was performed to repair the aneurysms with grafts from the great saphenous vein. Both patients had uneventful postoperative courses. CONCLUSIONS The optimal treatment for the patients described was open surgical repair because the lower risk of occlusion of the visceral branch made it safer and more reliable than an endovascular approach.

Levels of phospholipids and triacylglycerol-containing omega 3 fatty acids in myocardial tissue of patients with myocardial infarction: analyzed by a lipidomics profiling method

Objective

According to population-based studies, low omega 3 fatty acid (omega3FA) intake and high levels of serum triacylglycerol (TAG) are associated with cardiovascular diseases. Recent advances in mass spectrometry allow molecular lipid (lipidomics) profiling, which may enhance cardiovascular risk prediction. In this study, we assessed the levels of omega3FA-containing phospholipids (PL) and TAG in myocardial tissues of patients with and without myocardial infarction (MI) using a lipidomics profiling method.

Methods

We performed lipidomics profiling of human left atrial appendage (LAA) tissue of 29 consecutive patients receiving off-pump coronary bypass surgery with standard LAA resection. The patients were divided into the MI group (n=7) and an age- and gender-matched non-MI group (n=7).

Results

Lipidomics profiling revealed that the MI group tended to have low levels of phosphatidylcholines (PC), phosphatidylethanolamine (PE), lysophosphatidylethanolamine (LPE), and plasmalogen, and high levels of TAG species. Individual molecular species containing omega3FA, such as PC (18:0/20:5; 3,200±1,200 vs. 4,500±910 pmol/g tissue, p=0.04) and plasmalogen (18:1/20:5; 57,000±21,000 vs. 91,000±28,000 pmol/g tissue, p=0.02), were significantly lower in the MI group than in the non-MI group.

Conclusions

To our knowledge, this is the first study to determine the levels of omega3FA-containing PL and TAG in myocardial tissue using lipidomics profiling. We discovered that lower levels of omega3FA-containing PL and higher levels of TAG existed in myocardial tissues of patients with MI than in those of patients without MI. Accordingly, the lipidomics profiling method for human myocardial tissue may be useful for developing therapy targets for cardiovascular diseases.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): MEXT/JSPS KAKENHI Grant

Impact of body mass index on the clinical outcomes in heart failure patients undergoing cardiac rehabilitation

Background

Increased body mass index (BMI) has recently shown to have a favorable effect on the prognosis in heart failure (HF) patients. However, the impact of BMI on clinical events and mortality in HF patients who underwent cardiac rehabilitation (CR) remains unclear.

Purpose

This study aimed to investigate whether the obesity paradox is present in HF patients who have undergone CR.

Methods

This study enrolled 238 consecutive HF patients who had undergone CR at our university hospital between November 2015 and October 2017. The clinical characteristics and anthropometric data of these patients, including BMI, were collected at the beginning of the CR. The major adverse cardiovascular event (MACE) was defined as a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data regarding the primary endpoints were collected until November 2018.

Results

Patients (mean age 68.7 years, male 61%) were divided into four groups as per BMI quartiles. More patients in the highest BMI group were women, were significantly younger, and had a higher prevalence of hypertension, dyslipidemia, and diabetes mellitus; however, no significant differences were observed in the prevalence of chronic kidney disease, left ventricular ejection fraction, and brain natriuretic peptide levels of the four groups. During a median follow-up duration of 583 days, 28 patients experienced all-cause mortality, and 42 were hospitalized for HF. Kaplan–Meier analysis showed that patients in the highest BMI quartiles had lower rates of MACE (Log-rank P&lt;0.05) (Figure 1). After adjusting for confounding factors, Cox regression multivariate analysis revealed that BMI was negatively and independently associated with the incidence of MACE (hazard ratio: 0.89, 95% confidence interval: 0.83–0.96, P&lt;0.05).

Conclusion

Increased BMI was associated with better clinical prognosis even in HF patients who have undergone CR Therefore, BMI assessment may be useful for risk stratification in HF patients who have undergone CR.

Figure 1. Kaplan-Meier survival curve

Funding Acknowledgement

Type of funding source: None

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.

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.

Factors influencing activated clotting time following heparin administration for the initiation of cardiopulmonary bypass

OBJECTIVES

Initiation of cardiopulmonary bypass (CPB) for open-heart surgery requires that heparin be administered and reach an adequate value of activated clotting time (ACT). We previously introduced a new heparin formula that considered the preoperative ACT. In this study, we determined other factors affecting ACT.

METHODS

Adult patients who underwent cardiac surgery using CPB were divided into two groups according to their ACT value after the initial administration of heparin during surgery. ACT above 450 s was defined as "Reach", and this group was compared to the "Short" group with ACT below 450 s.

RESULTS

The Reach and Short groups included 334 (64.7%) and 182 (35.3%) cases, respectively. Univariate analysis indicated that preoperative heparin use, age ≥ 80 years, New York Heart Association classification 4, white blood cell counts above the higher limit, hematocrit below the lower limit, platelet cell counts below the lower limit, low albumin levels, moderate renal dysfunction, high C-reactive protein levels, high brain natriuretic peptide levels, and moderate deterioration of left ventricular ejection fraction were associated with the effects of heparin. Multivariate analysis revealed that age ≥ 80 years (odds ratio [OR] 2.53, 95% confidence interval [95%CI] 1.41-5.24), New York Heart Association classification 4 (OR = 4.44, 95%CI 1.59-15.35), and platelet count below the lower limit (OR 0.37, 95%CI 0.31-0.85) were associated with the effects of heparin.

CONCLUSION

Old age, heart failure, and lower platelet counts affected heparin activity. The dose of heparin should be considered in those patients to reach the target ACT.

Efficacy and Safety of 1:1 Fixed-Ratio Combination of Insulin Glargine and Lixisenatide Versus Lixisenatide in Japanese Patients With Type 2 Diabetes Inadequately Controlled on Oral Antidiabetic Drugs: The LixiLan JP-O1 Randomized Clinical Trial

OBJECTIVE

To assess the efficacy and safety of a 1:1 fixed-ratio combination of insulin glargine and lixisenatide (iGlarLixi) versus lixisenatide (Lixi) in insulin-naive Japanese patients with type 2 diabetes mellitus (T2DM) inadequately controlled on oral antidiabetic drugs (OADs).

RESEARCH DESIGN AND METHODS

In this phase 3, open-label, multicenter trial, 321 patients with HbA_1c≥7.5 to ≤10.0% (58-86 mmol/mol) and fasting plasma glucose (FPG) ≤13.8 mmol/L (250 mg/dL) were randomized 1:1 to iGlarLixi or Lixi for 52 weeks. The primary end point was change in HbA_1c at week 26.

RESULTS

Change in HbA_1c from baseline to week 26 was significantly greater with iGlarLixi (-1.58% [-17.3 mmol/mol]) than with Lixi (-0.51% [-5.6 mmol/mol]), confirming the superiority of iGlarLixi (least squares [LS] mean difference -1.07% [-11.7 mmol/mol], P < 0.0001). At week 26, significantly greater proportions of patients treated with iGlarLixi reached HbA_1c <7% (53 mmol/mol) (65.2% vs. 19.4%; P < 0.0001), and FPG reductions were greater with iGlarLixi than Lixi (LS mean difference -2.29 mmol/L [-41.23 mg/dL], P < 0.0001). Incidence of documented symptomatic hypoglycemia (≤3.9 mmol/L [70 mg/dL]) was higher with iGlarLixi (13.0% vs. 2.5%) through week 26, with no severe hypoglycemic events in either group. Incidence of gastrointestinal events through week 52 was lower with iGlarLixi (36.0% vs. 50.0%), and rates of treatment-emergent adverse events were similar.

CONCLUSIONS

This phase 3 study demonstrated superior glycemic control and fewer gastrointestinal adverse events with iGlarLixi than with Lixi, which may support it as a new treatment option for Japanese patients with T2DM that is inadequately controlled with OADs.

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.

Changes in polysomnographic findings following transcatheter aortic valve implantation in a patient with aortic stenosis

Patients with aortic stenosis (AS) are likely to have sleep-disordered breathing (SDB) and improvements in AS by transcatheter or surgical aortic valve replacement alter the type and severity of SDB. However, limited data are available whether polysomnographic findings changed following transcatheter aortic valve implantation (TAVI). In this report, we describe the case of a patient with severe AS and SDB whose polysomnographic findings showed that after TAVI, sleep disturbances occurred in association with worsened periodic leg movements despite improvement in the SDB. <Learning objectives: Patients with aortic stenosis often have sleep-disordered breathing (SDB) which can be improved following transcatheter aortic valve implantation (TAVI). However, no studies assessed SDB by polysomnography before and after TAVI. Following TAVI, our case revealed sleep disturbances associated with worsened periodic leg movements (PLM) despite improvement of SDB. Therefore, polysomnography may be considered following TAVI to detect residual SDB and sleep disturbance in association with PLM.>.

Coronary Revascularization of Giant Aneurysms in Children With Kawasaki Disease: A Report of Two Cases

In recent years, >100 cases of coronary artery stenotic lesions due to Kawasaki disease were treated with coronary artery bypass grafting (CABG). Surgical indications include stenosis of >75%, myocardial infarction history, electrocardiographic changes, and ischemia, as detected by myocardial scintigraphy and electrocardiography, due to drugs or exercise. Some centers have reported good patency rates, even in infants. The advantages of CABG in younger patients are minimal loss of left ventricular function, early elimination of post-operative ischemia risk, and improved quality of life. However, the disadvantage of performing CABG in younger patients is the small coronary artery diameter and the thin vessel wall, which can lead to post-operative occlusion, especially when performed by inexperienced surgeons. The optimal timing of CABG varies by institution and case, which depends on the presence or absence of complications, such as left ventricular dysfunction or valve regurgitation, and surgeon's experience. Importantly, unlike adult surgery, childhood CABG needs to be kept open for the very longest possible period of time to determine the optimal conditions for surgery. We report two pediatric cases of giant coronary artery aneurysms diagnosed in infancy. During school age, the patients had a mild decline of left ventricular ejection function. In one case, there were no clinical symptoms because of the development of collateral vessels and limitation of exercise. Both patients underwent surgery with good results. The gastric gastroepiploic artery could be anastomosed owing to the development of collateral blood vessels, although it was obstructed. At 1 year after surgery, both patients had a good post-operative course without complications of anastomotic stenosis or myocardial damage due to aneurysm resection. If conditions are favorable, bypass surgery can be postponed to several years until the coronary arteries are sufficiently large to warrant a delay in coronary artery stenosis in cases of infantile Kawasaki disease.

P2861Elevated cc chemokine receptor 2 expression and higher migratory activity of monocytes in atrial fibrillation patients with progressive structural remodeling

Background

Inflammation in atrial tissue underlies structural remodeling of left atrium, which is a hallmark of atrial fibrillation (AF). Activated monocytes mediate inflammation; however, the role of monocytes in AF pathogenesis has not been extensively examined. In this study, we thus investigated the association between structural remodeling of left atrium, represented by left atrial dimension (LAD), and characteristics of peripheral monocytes in patients with AF.

Methods

Blood samples were collected from patients undergone catheter ablation between July 2017 and October 2018, including AF patients (n=152) and paroxysmal supraventricular tachycardia (PSVT) patients, which serves as a control non-AF group (n=22). AF patients were further divided into two groups by the median of LAD (normal LAD group: LAD <40 mm, n=77, large LAD group: LAD ≥40 mm, n=75). Peripheral blood mononuclear cells (PBMC) were isolated to analyze monocyte subsets by flow cytometry. In a subset of patients, we further isolated monocytes from PBMC by using magnetic bead-based negative selection method then gene products associated with inflammation or monocyte functions were evaluated. We also examined migratory activity of monocytes toward monocyte chemotactic protein-1, a ligand for CC chemokine receptor 2 (CCR2), using a modified Boyden chamber method. Finally, we performed immunofluorescence staining of monocytes and macrophages in left atrial appendages resected from patients underwent coronary bypass graft surgery (CABG) complicated by AF.

Results

There were no differences in age, body mass index and high-sensitivity C-reactive protein levels among three groups, including non-AF, normal LAD and large LAD groups, except that more female subjects were included in non-AF group. We found that proportions of classical CD14++CD16- and nonclassical CD14+CD16++ monocytes were higher (non-AF: 71.2±7.3% vs. AF: 75.5±8.3%, p<0.05) and lower (non-AF: 16.4±5.9% vs. AF: 13.2±5.5%, p<0.05), respectively, in all AF patients compared with those in non-AF group, while no significant difference was observed between normal and large LAD groups. In monocytes from large LAD group, mRNA levels of CCR2, a receptor to mediate monocyte chemotaxis, were significantly higher compared to those in normal LAD group (Figure A, p<0.05). Furthermore, monocytes isolated from large LAD group exhibited higher migratory capacity compared to normal LAD group (Figure B, p<0.01). Finally, higher monocyte/macrophage infiltrations to left atrial appendages were implicated in patients with large LAD, shown by immunofluorescence staining.

Conclusions

Monocytes in AF patients with enlarged left atrium expressed higher CCR2 mRNA and were more active in chemotaxis to MCP-1, suggesting the proactive roles of activated monocytes in the pathogenesis of arterial remolding in AF.

P6209Relationship between skin autofluorescence levels and clinical outcomes in heart failure patients 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.

Purpose

The purpose of this study was to investigate the prognostic value of SAF levels 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. The 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 2018.

Results

Patients' mean age was 68.1 years, and 61% were males. 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 histories 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 median follow-up period of 623 days, 25 patients experienced all-cause mortality and 34 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), whereas when patients were divided into two groups according to the median hemoglobin A1c level, no significant between-group difference was observed for the incidence of MACE (Figure). After adjusting for confounding factors, Cox regression multivariate analysis revealed that SAF levels were independently associated with the incidence of MACE (hazard ratio: 1.74, 95% confidence interval: 1.12–2.65, P<0.05).

Figure 1

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 undergo CR.