Impact of in-hospital medical management for COVID-19 pandemic on door-to-balloon time in patients with ST-elevation myocardial infarction

Background

Delayed door-to-balloon (DTB) time and deterioration of in-hospital mortality during the coronavirus disease 2019 (COVID-19) pandemic have been reported. Little is known about the impact of changes in in-hospital medical management before primary percutaneous coronary intervention (PCI) for COVID-19 such as screening test (antigen or polymerase chain reaction (PCR) tests, chest CT for excluding the pneumoniae) and primary PCI under full personal protective equipment (PPE) on DTB time and in-hospital mortality.

Purpose

The purpose of this study was to evaluate the impact of in-hospital medical management for COVID-19 on DTB time and in-hospital mortality during COVID-19 pandemic period.

Methods

We compared DTB time and in-hospital mortality of 502 ST-elevation myocardial infarction (STEMI) patients during COVID-19 pandemic (February 2020 and January 2021) with 2035 STEMI patients before pandemic (February 2016 and January 2020) using date from Mie ACS registry, a retrospective and multicenter registry.

Results

The COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was performed on 173/502 (34.5%) patients (antigen or PCR tests; 39 (7.8%), chest CT; 156 (31.3%), full PPE; 11 (2.2%)). These patients had lower rate of achievement of DTB time ≤90 min compared with others (Figure 1A). Moreover, In-hospital management of COVID-19 screening tests and/or primary PCI under full PPE was an independent factor of DTB time>90 min with odds ratio of 1.94 (95% confidential interval: 1.37–2.76, p<0.001). In addition, in-hospital mortality of those patients was higher compared with others (Figure 1B).

Conclusion

In-hospital medical management for COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was the independent factor of DTB time>90 min. This study reinforces the need to focus efforts on shortening DTB time, while controlling the epidemic of infection.

Funding Acknowledgement

Type of funding sources: None.

Horizontal orientation facilitates pollen transfer and rain damage avoidance in actinomorphic flowers of Platycodon grandiflorus

In zoophilous plants, floral orientation evolved under both biotic and abiotic pressure to enhance pollination success. However, the adaptive significance of horizontal orientation in radially symmetrical (actinomorphic) flowers remains largely unknown, although that of bilaterally symmetrical flowers has been well studied. We experimentally altered floral angle in a population of insect-pollinated Platycodon grandiflorus flowers to examine the effects of floral orientation on pollinator behaviour, pollination success and pollen rain damage avoidance. To further investigate the potential pollen damage by rain, we obtained past precipitation records for the study area during the flowering season, and experimentally tested P. grandiflorus pollen damage by water. Horizontally oriented flowers received more pollinator visits and had pollen grains on the stigma in male and/or female phases than downward- and/or upward-oriented flowers and avoided pollen damage by rainfall better than upward-oriented flowers. A pollen germination experiment showed that approximately 30% of pollen grains burst in distilled water, indicating that pollen damage by rainfall may be significant in P. grandiflorus. Our field experiments revealed that upward-oriented flowers cannot avoid pollen damage by rainfall during the flowering period, and that both upward- and downward-oriented flowers experience pollinator limitation in female success. Therefore, horizontal flower orientation appears to be adaptive in this insect-pollinated actinomorphic species that blooms during the rainy season.

Expression and roles of N-type Ca channel in cardiaomyocytes

Background

Voltage dependent Ca channels are divided to L-, T-, N-, P/Q-, and R-types, and N-type Ca channel (NCC) is mainly expressed in nerve terminal and regulates neurotransmitter release. Recently, NCC has been reported to express in adrenal gland and renal tubular cells. We examined whether NCC is expressed in cardiac myocytes and if so, the roles of this channel.

Methods

Expression of NCC mRNA and protein in cardiomyocytes were assessed by quantitative real time PCR and Western blot analysis using neonatal rat cultured cardiomyocytes, infant, and adult rat hearts. Expression site of NCC in cardiomyocytes was examined by confocal imaging of immunofluorescent staining. The roles of NCC in physiological Ca transient in neonatal myocytes were examined using fluorescence imaging of Fluo4, an intracellular Ca indicator. To examine the effects of pathological condition, such as heart failure and ischemia-reperfusion, on NCC expression, cultured cardiomyocytes were treated with norepinephrine (10 μmol/L, 24 hours) or subjected to 5 hours of hypoxia followed by 30 minutes of reoxygenation. In addition, adult rats were subjected to myocardial infarction by ligating the left anterior coronary artery. Lethal myocyte injury was examined by LDH activity in culture medium and myocyte apoptosis was examined by nuclear staining with DAPI and caspase 3 activity. To clarify the roles of NCC in neonatal myocytes in these pathological conditions, we examine the effect of ω-conotoxin, a selective NCC blocker.

Results

NCC mRNA and protein were expressed in neonatal cardiomyocytes. Immunocytochemical staining showed NCC was expressed in myocyte plasma membrane. During physiological spontaneous beating, ω-conotoxin did not affect beating rate and intra cellular Ca transient, suggesting that the roles of NCC on physiological beating are little. After birth level of NCC mRNA expression in cardiac tissue gradually decreased within 2 weeks and low level of mRNA expressed continuously in adult cardiac tissue. However, in pathological condition, mRNA and protein levels of NCC in non-infarcted region were increased 4 weeks after myocardial infarction. In addition, hypoxia-reoxygenation and norepinephrine administration increased LDH release and myocyte apoptosis in association with increase in NCC expression in neonatal cultured myocytes. ω-conotoxin significantly suppressed hypoxia/reoxygenation- and norepinephrine-induced LDH release and caspase 3 activation.

Conclusion

NCC is expressed in neonatal cardiac myocytes and the expression level was decreased after birth. Pathological condition, such as ischemic heart disease and heart failure, upregulated NCC expression in cardiomyocytes and NCC exacerbated lethal myocyte injury, while roles of NCC in physiological beating are little.

Funding Acknowledgement

Type of funding sources: None.

Creation of mortality risk calculator using a I-123 mIBG-based machine learning model: differential prediction of arrhythmic death and heart-failure death

Funding Acknowledgements

Type of funding sources: None.

Background

Although I-123 meta-iodobenzylguanidine (mIBG) has been applied to patients with chronic heart failure (CHF), a diagnostic tool for differential prediction of fatal arrhythmic events (ArE) and heart-failure death (HFD) has been pursued. 

Purpose

The aim of this study was to create a calculator of mortality risk for differentiating mode of cardiac death using a machine learning (ML) method, and to test the accuracy in a new cohort of patients with CHF.

Methods

A total of 529 patients with CHF was used as the training database for ML. The ArE group consisted of patients with arrhythmic death, sudden cardiac death and appropriate therapy by implantable cardioverter defibrillator. A heart-to-mediastinum ratio (H/M) standardized to the medium-energy collimator condition was calculated with a planar anterior mIBG scintigram. The best classifier models for predicting HFD and ArE were determined by four-fold cross validation. Input variables included age, sex, New York Heart Association (NYHA) functional class, left ventricular ejection fraction, ischemic etiology, mIBG H/M and washout rate, and b-type natriuretic peptide (BNP) or NT Pro BNP, estimated glomerular filtration rate, hemoglobin, and complications such as diabetes and hypertension. After creating the ML-based model, the constructed classifier functions for ArE, HFD, and survival were exported for subsequent use. A new cohort of patients (n = 312, age 67 ± 13 years, 2015 or later) was used to test the ML-based model.

Results

The training database included 141 events (27%) with ArE (7%) and HFD (20%). Receiver-operating characteristic analysis by four-fold validation showed area under the curve value of 0.90 for HFD and 0.73 for ArE. Among various ML methods, the logistic regression method demonstrated the most stable calculation of the probability of ArE followed by random forest and gradient boosted tree methods. Therefore, the logistic-regression method was used for calculating both HFD and ArE probabilities. In the test cohort, patients with a high HFD probability >8% resulted in 6.3-fold higher HFD than those with low probability (≤ 8%). Patients with high ArE probability >8% showed 2.5-fold higher ArE than those with low probability (≤ 8%).

Conclusion

The ML-based mortality risk calculator could be used for stratifying patients at high and low risks, which might be useful for estimating appropriate treatment strategy.

Premature acute coronary syndrome patients do not have a better prognosis for their age than mature ACS patients by propensity score match analysis

Background

Acute coronary syndrome (ACS) is the most important cardiovascular (CV) disease with a prevalence that increases with age. There is no data which compared the prognosis with premature ACS and mature ACS using propensity score matched analysis

Purpose

The purpose of this study was to compare the prognosis of premature ACS patients and mature ACS patients using propensity score matched analysis.

Methods

We analyzed of 4249 ACS patients (69.1±12.6, male 77%) including 773 premature ACS patients (50.1±6.8, male 78%) and 3476 mature ACS (73.3±9.3, male 77%) from January 2013 to December 2018, using data from Mie ACS Registry, a prospective and multicenter registry in Japan.

Premature onset of ACS was defined as younger than 65 years old in male and 55 years old in female.

Primary end point was as major adverse cardiac event (MACE) including cardiovascular death, non-fetal myocardial infarction, heart failure requiring admission and unstable angina.

Results

During median follow duration of 742 days ranging from409 to 828 days, 502 MACE were occurred. Premature ACS patients were younger and showed higher body mass index compared to mature ACS patients (50.1±6.8 vs 73.3±9.3 y.o., 25.5 vs 23.0, P<0.001, respectively). However, premature ACS patients were more likely to be associated with ST elevation myocardial infarction, dyslipidemia, family history of coronary artery disease (CAD) and lower Killip classification compared to mature ACS patients (P<0.01, respectively). Common CAD risk factors such as hypertension, diabetes mellitus and past history of CAD were less associated with premature ACS patients compared to mature ACS patients (P<0.01, respectively). Unadjusted Kaplan-Meier survival curves demonstrated the favorable prognosis in premature ACS patients compared to mature ACS patients with hazard ratio of 0.57 (95% CI 0.45–0.71, P<0.001, see Figure 1A). We compared a 1:1 propensity score-matched cohort of 1208 patients with or without premature onset of ACS adjusting the several factors mentioned above (n=604, respectively). Age could not be introduced as a factor of propensity score match when comparing premature and mature ACS patients. After propensity score-match, premature ACS patients is about 18 years younger than mature ACS patients (50.7±6.5 vs 68.5±8.2 y.o., P<0.001). The average age of premature ACS was younger than that of mature ACS, but MACE by Kaplan-Meier survival analysis for premature ACS patients was equivalent to mature ACS patients (P=0.77, see Figure 1B).

Conclusion

Premature ACS patients are required very careful management because they might have factors with unfavorable prognosis, such as lifestyle habit and genetics, that may be beyond age.

Figure 1

Funding Acknowledgement

Type of funding source: None

Evaluation of temporal changes in longitudinal strain distribution during the systolic period to determine left ventricular activation sequence: a study using 2D speckle-tracking echocardiography

Background

Evaluation of two-dimensional (2D) speckle-tracking longitudinal strain (LS) is useful for assessing global and regional left ventricular (LV) dysfunction.

Purpose

The purpose of this study was to test the hypothesis that temporal changes in regional 2D-LS distribution, (i.e., changes in area and intensity of the negative strain), during the systolic period may reflect the LV activation sequence.

Methods

We studied 52 patients with an ejection fraction <35% who were classified into four groups: complete left bundle branch block (LBBB, QRS 162±17 ms, n=17); right ventricular pacing from inferior septum (RVP, QRS 180±29 ms, n=16); left VP from lateral branch of the coronary sinus (LVP, QRS 182±21 ms, n=9); and no conduction block (Narrow QRS, QRS 100±9 ms, n=19). Longitudinal strain was evaluated in three standard apical views, and then bulls-eye distribution maps were constructed every 50 ms from the QRS onset to aortic valve closing (AVC) and at the time of the end of QRS. Segments indicating negative strain at the end of QRS were regarded as an early contraction site. Segments with intensifying negativity of strain as it got closer to the AVC were regarded as a late contraction site.

Results

In patients with LBBB, negative strain appeared initially in the septum region. Then, the contracted area enlarged including the apical region, and the basal lateral region contracted late. On the other hand, Narrow QRS showed a few regional differences in strain at the end of QRS (standard deviation in 17-segments: Narrow QRS 1.3±0.4%*, LBBB 3.3±1.1%, RVP 3.2±1.0%, LVP 3.3±1.1%, *p<0.001), and contracted homogeneously during the systolic period. RVP and LVP showed negative strain at the end of QRS in septum and lateral regions respectively, with the contracted area becoming enlarged towards the opposite regions of the early contracted regions.

Conclusion

The 2D-LS distribution during the systolic period reflects the LV contraction process in patients with an altered ventricular activation sequence, and may have potential for identifying the regions of early activation site and subsequent activation propagation.

Funding Acknowledgement

Type of funding source: None

P37 Long-term outcomes of patients at risks for Fontan operation: role of temporary fenestration

Purpose

Whereas fenestration at Fontan operation was reported to be effective for smooth initiation to Fontan circulation, subsequently developed aortopulmonary collateral arteries under the presence of remaining hypoxia were a matter of concern.So as our institutional policy, it is closed as much and early as possible (temporary fenestration). This study aimed to reveal long-term outcomes for patients at riskswho underwent Fontan operation with temporary fenestration.

Methods

Of 107 patients undergoing Fontan operation from 1995 to 2004, 79 patients (73.8%) were free from any risks (NR group) and 28 patients (26.2%) had risks for Fontan operation (R group). Hypoplastic left heart syndrome, heterotaxy syndrome with obstructive total anomalous of pulmonary venous connection, and individual cases with high preoperative pulmonary artery pressure (PAP), systemic ventricular end diastolic pressure (SVEDP) or low ejection fraction (SVEF) were defined as a risk for Fontan completion.Age at Fontan operation was older in R group (6.6 vs 2.3years-old, p = 0.0004). Preoperative PAP (12.8 vs 11.3mmHg, p = 0.03) and SVEDP (8.8 vs 7.1mmHg, p = 0.02) were higher and SVEF (53.7 vs 60.0%, p = 0.002) was lower in R group. Pulmonary vascular resistance (PVR) was not different. Fenestration was created in all patients in R group, then it was closed at the mean duration of 2.9 years after Fontan operation.

Results

Freedom from death or protein-losing enteropathy rate at 5, 10, and 15 years after Fontan operation were 97, 96, and 93% in NR group and 96, 93, and 86% in R group (log-rank: p = 0.20). Fifty-one patients (64.6%) in NR group and 17 patients (60.7%) in R group underwent serial catheter examinations at 5, 10, and 15 years after Fontan operation and exercise capacity testing at 15 years after Fontan operation (Figure). In R group, arterial oxygen saturation was lower and PVR was higher even after close of fenestration (Figure). In addition, 12 patients (71%) in R group developed significant veno-venous collaterals, which were defined by more than 3mm in diameter of collateral veins or a condition where pulmonary veins were contrasted in venography. On the contrary, cardiac index (CI), SVEDP, and PAP were not different and no significant difference on peak oxygen uptake and anaerobic threshold were observed between in 2 groups. 

Conclusions

Although the mild cyanosis remained due to the development of veno-venous collaterals after the closure of temporary fenestration, CI, SVEDP and PAP well maintained in patients at risk for Fontan operation. These results might to lead acceptable life prognosis and freedom fromprotein-losing enteropathy rate for patients at risk for Fontan operation.

Abstract P37 Figure

P713Short term treatment of a low dose erythropoietin improves vascular function in a rat model of insulin resistance

Background/Introduction

Erythropoietin (EPO) exerts haematopoiesis-independent cardiovascular and renal protective effects by binding to EPO receptors expressed in hearts, arteries, and kidneys. We have reported that EPO inhibits vascular and renal injury in rat models of hypertension and type 1 diabetes. Recent studies report that EPO improves glucose tolerance in insulin resistant animals.

Purpose

This study investigated whether EPO would inhibit vascular and renal dysfunction in the setting of insulin resistance.

Methods

Rats were treated with sucrose (12% in drinking water) for 10 weeks to induce insulin resistance. EPO (3 times/week, s.c) was administered at the dose of 150U/kg for 10 weeks from the beginning (group A) or at the dose of 75U/kg for the last 4 weeks (group B) of sucrose treatment. Blood pressure was measured every second week by the tail-cuff method. HOMA-IR, haematocrit, and urinary protein excretion were measured. Using isolated aortas, acetylcholine-induced vasorelaxation under phenylephrine-induced pre-contraction was examined. Aortic sections were stained with haematoxylin-eosin.

Results

Both groups A and B showed higher haematocrit levels compared with the control and sucrose alone-treated groups. Sucrose treatment increased HOMA-IR (7.7±2.0 vs. 24±4.5, p<0.05), which was attenuated in groups A (3.6±0.9) and B (9.7±4.0). EPO treatment (150U/kg) had no effects on blood pressure for the first 4 weeks but caused time-dependent increases in blood pressure from the 6th week. Increased proteinuria and impaired aortic vasorelaxation in sucrose-treated rats were exacerbated by EPO (150U/kg) maybe because of hypertension (Control 122±2mmHg, Sucrose 125±2mmHg, group A 148±5mmHg), one of the major side effects of EPO. According to these results, we treated a half dose of EPO only for the last 4 weeks (group B). A lower dose of EPO treatment for a shorter period did not increase proteinuria (Control 15±2mg/day, Sucrose 25±3mg/day, group B 24±3mg/day) despite a mild increase in blood pressure (132±2mmHg). Impaired endothelium-dependent vasodilation and aortic thickening in the aorta of sucrose alone-treated rats were attenuated by lower and shorter EPO treatment (group B).

Conclusions

EPO inhibited insulin resistance and vascular injury in sucrose-induced insulin resistant rats. Further investigation into the mechanisms of tissue protective effects of EPO, especially focusing on the effects on insulin signalling in not only hepatic and muscle cell but also vascular and renal cells, will be needed.

P6275Role of autophagy in imatinib-induced cardiotoxicity

Background

Cardiotoxicity is one of the severe adverse effects of chemotherapeutic agents. Imatinib, a therapeutic agent for chronic myelogenous leukemia, has been reported to induce cardiotoxicity. Autophagy is an intracellular bulk protein and organelle degradation process, but it is unclear whether autophagy functions as pro-death or pro-survival program during disease conditions. We examined whether imatinib induces myocyte autophagy and the role of autophagy in imatinib-induced cardiotoxicity in in vitro and in vivo experiments.

Methods

In in vitro experiments, neonatal rat cardiac myocytes were treated with imatinib (1, 5, 10 μM; 1–6 hrs). Inhibition of autophagy was performed using 3-methyl-adenine (3MA), an autophagic inhibitor, and transfection with Atg5-targeted siRNA. Myocyte apoptosis was detected by morphological change in nuclei and caspase 3 activity. Mitochondria-derived reactive oxygen species production was detected using MitoSOX and mitochondrial membrane potential was assessed by TMRM staining. Expressions of cytochrome c in mitochondria and cytosole were examined by Werstern blotting. Myocyte autophagy was assessed by monodansylcadaverine staining and microtubule-associated protein light chain (LC) 3-II expression. In in vivo experiments, C57BL6 mice were treated with imatinib (50 and 200 mg/kg/day) for 5 weeks in the presence or absence of 3MA. Cardiac function was examined by echocardiography. In cardiac tissue, apoptotic myocytes were examined by TUNEL assay and autophagy was examined by LC3-II expression.

Results

In in vitro experiments, imatinib increased apoptotic nuclei and caspase 3 activity, in a dose-dependent manner. Consequently, imatinib augmented production of mitochondria-derived reactive oxygen species, loss of mitochondrial membrane potential, and the release of cytochrome c from mitochondria to cytosole, suggesting that imatinib induced mitochondrial-apoptotic pathway. On the other hand, imatinib significantly increased monodansylcadaverine stained dots and LC3-II expression, suggesting that imatinib increased autophagy. 3MA and Atg5 siRNA augmented imatinib-induced apoptosis by 60% and 30%, respectively. In in vivo experiments, imatinib (200 mg) exhibited the dilatation of left ventricle by 15% and the depression of left ventricular fractional shortening by 23%. Ratio of apoptotic myocytes was significantly increased and LC3-II expression in cardiac tissue was enhanced by imatinib in a dose-dependent fashion. Co-treatment with 3MA and imatinib further impaired imatinib-induced myocyte apoptosis by 3 fold and LV dysfunction by 20%.

Conclusion

These results indicate that imatinib induced myocyte apoptosis, leading to cardiac dysfunction. Imatinib enhanced myocyte autophagy as a consequence of apoptosis and autophagy was a beneficial phenomenon in this condition.

P1603Nicorandil suppresses ischemia-induced cardiac interstitial norepinephrine enhancement and ventricular arrhythmia in hypertrophic hearts

Background

Myocardial infarction (MI) is a major cause of death in western countries and Japan, and hypertension is a major risk factor of MI. In hypertensive heart, acute myocardial infarction often leads to lethal ventricular arrhythmia. Nicorandil, an ATP sensitive potassium channel (KATP) opener, is usually used in the treatment of acute myocardial infarction. The effects of nicorandil on ischemic myocyte are fully defined. On the other hand, KATP in neuroterminals is known to regulate norepinephrine release, but the effect of nicorandil on ischemic norepinephrine release in cardiac tissue has remained unexplored.

Purpose

We examined whether nicorandil suppressed norepinephrine release via neuronal KATP and ventricular arrhythmia during acute ischemia in pressure overload-induced hypertrophic hearts.

Methods

SD Rats were divided into two groups; abdominal aortic constriction (AAC) group and sham-operated (Sham) group. Four weeks after constriction, cardiac geometry and function were examined using echocardiography. Then, myocardial ischemia was induced by the left anterior descending artery occlusion for 100 minutes in the presence or absence of intravenous infusion of nicorandil. Cardiac interstitial norepinephrine concentration in ischemic region was measured using the microdialysis method and concentration of cyclic AMP, a second messenger of norepinephrine, in cardiac tissue was measured by ELISA. Ventricular arrhythmias were monitered by ECG during whole ischemic period.

Results

Four weeks after constriction, remarkable left ventricular wall thickening was observed in AAC group. Before ischemia, ventricular arrhythmia was not found in both groups. Number of ventricular arrhythmia, including ventricular tachycardia and ventricular fibrillation, was increased in early ischemic period (- 40 min) in both groups, and was grater in AAC group. Before ischemia, interstitial norepinephrine concentration in cardiac tissue was higher level in AAC group than in Sham group. Ischemia obviously increased norepinephrine concentration in both groups time dependently and AAC further increased norepinephrine than Sham group. Concentration of cyclic AMP in cardiac tissue was raised in early ischemic period (- 40 min) and then gradually decreased. Nicorandil significantly suppressed the number of ventricular arrhythmias, and abolished the ventricular tachycardia and fibrillation without hemodynamic alterations. Nicorandil also attenuated norepinephrine and cAMP enhancement in acute ischemic period in both groups.

Conclusion

Ischemia-induced ventricular arrhythmia was more frequent and severe in hypertrophic hearts and interstitial norepinephrine enhancement may play a role in this ischemic arrhythmia. Nicorandil suppressed ischemia-induced interstitial norepinephrine release by neuronal KATP opening, which attenuated ventricular arrhythmias in normal and hypertrophic hearts.

Longitudinal Findings of MRI and PET in West Syndrome with Subtle Focal Cortical Dysplasia

BACKGROUND AND PURPOSE

Despite the development of neuroimaging, identification of focal cortical dysplasia remains challenging. The purpose of this study was to show the longitudinal changes of MR imaging and FDG-PET in patients with West syndrome and subtle focal cortical dysplasia.

MATERIALS AND METHODS

Among 52 consecutive patients with West syndrome, 4 were diagnosed with subtle focal cortical dysplasia on 3T MR imaging. MR imaging and PET findings were evaluated longitudinally at onset and at 12 and 24 months of age.

RESULTS

At the onset of West syndrome, MR imaging demonstrated focal signal abnormalities of the subcortical white matter in 2 patients. In the other 2 patients, focal subcortical high-intensity signals became visible on follow-up T2WI as myelination progressed. PET at onset showed focal cortical hypometabolism in 3 patients, with 1 of these patients also having focal hypermetabolism and 1 having normal findings. On PET at 24 months, hypometabolism persisted in 2 patients and disappeared in 1, and hypermetabolism disappeared in 1. In 1 patient with normal MR imaging and PET findings at onset, focal hyperintensity and hypometabolism first appeared at 24 months of age. The findings on MR imaging and PET in these patients evolved differently with brain maturation and the clinical course.

CONCLUSIONS

Subtle focal cortical dysplasia can be undetectable on MR imaging at the onset of West syndrome and is not always accompanied by hypometabolism or hypermetabolism on PET. Longitudinal MR imaging and PET studies may be useful for detecting such lesions. Even in West syndrome with a congenital structural abnormality, PET findings evolve differently with brain maturation and the clinical condition.

Breeding phenology and winter activity predict subsequent breeding success in a trans-global migratory seabird

Inter-seasonal events are believed to connect and affect reproductive performance (RP) in animals. However, much remains unknown about such carry-over effects (COEs), in particular how behaviour patterns during highly mobile life-history stages, such as migration, affect RP. To address this question, we measured at-sea behaviour in a long-lived migratory seabird, the Manx shearwater (Puffinus puffinus) and obtained data for individual migration cycles over 5 years, by tracking with geolocator/immersion loggers, along with 6 years of RP data. We found that individual breeding and non-breeding phenology correlated with subsequent RP, with birds hyperactive during winter more likely to fail to reproduce. Furthermore, parental investment during one year influenced breeding success during the next, a COE reflecting the trade-off between current and future RP. Our results suggest that different life-history stages interact to influence RP in the next breeding season, so that behaviour patterns during winter may be important determinants of variation in subsequent fitness among individuals.

Switching to an L/N-type calcium channel blocker shows renoprotective effects in patients with chronic kidney disease: the Kyoto Cilnidipine Study

OBJECTIVE

This open-label, randomized controlled trial investigated the effects of cilnidipine, an L/N-type calcium channel blocker (CCB), in patients with chronic kidney disease (CKD).

METHODS

Sixty patients with CKD and well-controlled hypertension being treated with a renin- angiotensin system (RAS) inhibitor and an L-type CCB (L-CCB) were randomly assigned either to switch from the L-CCB to cilnidipine after a 4-week observation period or to continue with L-CCB treatment. Blood pressure, heart rate and renal function were monitored for 12 months. Data were available for analysis from 50 patients: 24 from the cilnidipine group and 26 from the L-CCB group.

RESULTS

Blood pressure was well controlled in both groups. After 12 months, proteinuria and heart rate were significantly decreased in the cilnidipine group, but proteinuria increased and heart rate remained unchanged in the L-CCB group. There was a significant positive correlation between the percentage changes in proteinuria and heart rate.

CONCLUSIONS

Cilnidipine has antihypertensive effects equivalent to those of L-CCBs. In patients with CKD, proteinuria can be decreased by switching from an L-CCB to cilnidipine, thereby improving renal function.

Aerodynamics of a bio-inspired flexible flapping-wing micro air vehicle

MAVs (micro air vehicles) with a maximal dimension of 15 cm and nominal flight speeds of around 10 m s⁻¹, operate in a Reynolds number regime of 10⁵ or lower, in which most natural flyers including insects, bats and birds fly. Furthermore, due to their light weight and low flight speed, the MAVs' flight characteristics are substantially affected by environmental factors such as wind gust. Like natural flyers, the wing structures of MAVs are often flexible and tend to deform during flight. Consequently, the aero/fluid and structural dynamics of these flyers are closely linked to each other, making the entire flight vehicle difficult to analyze. We have recently developed a hummingbird-inspired, flapping flexible wing MAV with a weight of 2.4-3.0 g and a wingspan of 10-12 cm. In this study, we carry out an integrated study of the flexible wing aerodynamics of this flapping MAV by combining an in-house computational fluid dynamic (CFD) method and wind tunnel experiments. A CFD model that has a realistic wing planform and can mimic realistic flexible wing kinematics is established, which provides a quantitative prediction of unsteady aerodynamics of the four-winged MAV in terms of vortex and wake structures and their relationship with aerodynamic force generation. Wind tunnel experiments further confirm the effectiveness of the clap and fling mechanism employed in this bio-inspired MAV as well as the importance of the wing flexibility in designing small flapping-wing MAVs.

Disease recurrence patterns after R0 resection of hilar cholangiocarcinoma

BACKGROUND

There is little information regarding the clinical behaviour of hilar cholangiocarcinoma after curative resection.

METHODS

A retrospective study was undertaken of 79 consecutive patients with hilar cholangiocarcinoma who had undergone major hepatectomy (three or more Couinaud segments) concomitant with caudate lobectomy, and had negative resection margins. Sites of initial disease recurrence were classified as locoregional (porta hepatis) or distant (intrahepatic, peritoneal, para-aortic lymph nodal or extra-abdominal). Univariable and multivariable analyses were performed to determine the factors potentially related to recurrence.

RESULTS

Disease recurrence was observed in 42 (53 per cent) of the 79 patients. Cumulative recurrence rates at 3 and 4 years after surgery were 52 and 56 per cent respectively. Locoregional recurrence alone was observed in eight (10 per cent) and distant metastasis in 34 (43 per cent) of the 79 patients after R0 resection. Positive nodal involvement and high International Union Against Cancer tumour (T) stage were independent prognostic factors associated with distant metastasis.

CONCLUSION

Distant metastases are more common than locoregional recurrence after R0 resection for hilar cholangiocarcinoma, and associated with nodal involvement and high T stage.

Expression Levels of Enzymes Related to In Situ Estrogen Synthesis and Clinicopathological Parameters in Breast Cancer Patients

Background: Local estrogen synthesis may play an important role of progression of breast cancer with hormone receptors. Local progression of breast cancer may depend on high concentration of estrogens and estrogen receptor status. To clarify correlation between expression levels of enzymes in breast cancer and clinicopathological parameters, we analyzed expression of steroid sulfatase(STS), estrogen sulfatase(EST), 17b-hydroxyl steroid dehydrogenase type I & II(17b-HSDI & II) and aromatase. In addition, mRNA expression of estrogens receptor alpha(ERa), estrogen receptor beta(ERb), cycline D1 and erbB2 were measured. Material and Methods: The mRNA expression levels of genes in 196 breast cancer tissues removed from surgery were assayed by RT-PCR. Results: The level of STS were significantly higher in patients with clinical stage. STS expressed none in stage 0 or I, 0.011 in stage II, and 0.013 amol/1 amol b-actin in stage 3 or 4. In addition, EST expressed 58.5 amol/1 amol b-actin in stage 2 and 36.8 in stage 3 or 4, otherwise, the expression level of EST in stage 0 or 1 revealed 15.3 amol/1 amol b-actin. There were no correlation between clinical stage and aromatase expression. Expression levels of ERa and cyclineD1 significantly correlated with protein levels of ER, and there were significant correlation between erbB2 expression and prognosis of patients. Conclusion: Up-regulation of STS play an important role in tumor progression of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4155.

[Bronchial schwannoma diagnosis by surgical treatment; report of a case]

18-year-old male was referred to our hospital due to persistent cough. The patient was admitted for the investigation of the abnormal shadow on a chest X-ray and chest computed tomography (CT). Chest CT showed a 2.5 cm nodular shadow in the right lower lobe. Bronchofiberscopy revealed the polypoid lesion at the right lower lobe bronchus obstructing the entire lumen of B8-10. The tumor surface was smooth and rich in small vessels. Right lower lobectomy was peformed. The diagnosis of schwannoma was confirmd with the S-100 positive immunohistochemical stain. Bronchial schwannoma is relatively rare disease; less than 90 cases have been reported with respect to schwannoma of case report in Japan.

[Aortic valve replacement for the patient with Osler-Rendu-Weber disease]

Osler Rendu-Weber (O-R W) disease (hereditary haemorrhagic telangiectasia) is characterized by an anormality of the peripheral blood vessels which often causes recurrent epistaxis. We presented a case of aortic valve replacement for the patient with O-R-W disease. A 75-year-old woman diagnosed as O-R-W disease with chest pain and dyspnea was admitted. Preoperative transthoratic echocardiography showed severe aortic valve stenosis (AS) with a pressure gradient (from left ventricle to ascending aorta) of 72.5 mmHg. Urgent aortic valve replacement (AVR) was performed after preoperative hormonal (estrogen-progesterone) therapy, that might be effective for bleeding from vascular ectasia. No hemorrhagic tendency was recognized and the postoperative course was uneventful.

[Surgical treatment for the patient with atrial septal defect and Andersen syndrome]

An 18-year-old girl with atrial septal defect and Andersen syndrome is reported. Andersen syndrome was described as a hereditary disease characterized by periodic paralysis, prolongation of the QT interval with ventricular arrhythmia and characteristic physical features including low set ear and micrognathia. We successfully performed cardiac operation for this rare associated malformation.

[Norwood procedure after colostomy; report of a case]

We encountered a baby who was diagnosed with anal atresia, interruption of aortic arch (type B), aortic stenosis, mitral stenosis, single atrium, large ventricular septal defects, aberrant origin right subclavian artery. We operated on him using the Norwood procedure after a colostomy. Aortic arch was reconstructed by interposing with an 8 mm graft and the right ventricular-pulmonary artery (RV-PA) conduit was chosen for pulmonary flow. We closed the sternum 6 days after the Norwood procedure. We extubated him 16 days after delayed sternal closure. There was no trouble with his stoma and no sign of infection. The postoperative echocardiography didn't show the finding which left pulmonary artery was stenotic, but the lung perfusion schintigraphy revealed an imbalance in the distribution of lung perfusion. He was discharged 70 days after undergoing the Norwood procedure.

[Successful repair of supravalvular aortic stenosis using Steinberg 3 sinuses reconstruction; report of a case]

Steinberg method is a modification of Doty extended aortoplasty for supravalvular aortic stenosis (SAS). This modification entails placement of an additional patch in the left coronary sinus. A 3-year-old boy was diagnosed as SAS with aortic valvular stenosis. He was noticed a systolic murmur from 1 month after his birth. Echocardiography showed left ventricular hypertrophy, and pressure gradient of 80 mmHg was measured between the ascending aorta and the left ventricle. Cardiac catheterization revealed severe aortic stenosis at the sino-tubular (ST) junction. We adopted Steinberg 3 sinuses reconstruction. After this operation, there was no pressure gradient at ST junction although aortic valvular stenosis remained and mild aortic valve regurgitation newly developed. As this method can produce a symmetric aortic root, it may reduce aortic valve deformity especially on the left coronary cusp.

[Surgical treatment for postinfarction ventricular septal perforation]

Between November 1985 and April 2003, surgical treatment for ventricular septal perforation (VSP) after acute myocardial infarction was performed in 16 patients. Patients were divided into 2 groups by method of operation. One group is infarct exclusion technique (n = 10). The other group is trans right ventricular (RV) approach (n = 6). No significant differences were observed between 2 groups in preoperative states. Operative death rate was high in both groups. Five patients (50%) were died in infarct exclusion group, 4 patients (67%) in trans RV group. Infarct exclusion technique needed longer extracorporeal circulation time (201 +/- 33 min) than trans RV approach (170 +/- 32 min). Although trans RV approach is attractive for its simplicity, 3 cases died of rupture of remained left ventricle infarction area. On the other hand, there were no mortality cases caused by left ventricle rupture in infarct exclusion technique group. As this result, we select infarct exclusion technique as a surgical correction for VSP.

Atomic force microscope of drug-DNA interaction

We have been investigated the possibility of B-Z transition in ZnTMPyP-DNA interaction based on the observation of spectroscopic data. In this study, we found drastic change in the AFM image of supercoiled plasmid DNA when it was interacted with TMPyPs indicating that the considerable amount of unwinding of double helix or B-Z transition is induced by the drug-DNA interaction. Such phenomena were not observed for other cationic drugs examined.

[Total aortic arch replacement with a right femur neck fracture on chronic renal dialysis; report of a successful case]

Although recent operative outcome for aortic arch aneurysm has been improved by various newly-devised assistant measures, satisfactory results have not been obtained in cases with serious preoperative complications, such as chronic renal failure. We present here an operative case of a 67-year-old woman on chronic hemodialysis with a calcified aortic arch aneurysm and a right femur neck fracture. First, we performed femur head replacement under careful hemodynamic control. After her mobilization was achieved, total aortic arch replacement was performed in "arch-first technique" using deep hypothermia plus retrograde cerebral perfusion in consideration of her calcified vessels. Her postoperative course was uneventful. We believe that early mobilization was a key for her recovery, because it was useful to prevent postoperative complications such as pulmonary infection and atelectasis. Our experience suggested that meticulous management throughout the whole perioperative course is very important for total aortic arch replacement in such complicated cases.

[Surgical treatment for giant ascending aorta-arch aneurysm coexisted with DeBakey type II dissection on elderly women: report of a case]

A 78-year-old woman was admitted to our hospital after computed tomography (CT) had revealed in her the presence of a giant ascending aorta-arch aneurysm. This aneurysm was about 8 cm in diameter and associated with DeBakey type II dissection. Aortography showed the same condition as the CT view with the entry on the ascending aorta. The ascending aortaarch was replaced with a Hemashield 24 mm, by using deep-hypothermic selective cerebral perfusion and the open distal method. There were no complications during her peripostoperative state and no evidence of leakage and remnant dissection on CT and aortography. This is a rare case in which thoracic aortic aneurysm coexisted with dissection. In this case of severe atherosclerosis, deep-hypothermic selective cerebral perfusion and the open distal method provided effective treatment.

Quantitative assessment of right ventricular structural abnormalities by right ventricular polar mapping of single photon emission computed tomogram

The identification of right ventricular (RV) abnormalities is clinically important in the evaluation of arrhythmogenic substrates in right ventricular-originated ventricular tachycardia (RVT). The purpose of this study was to determine the diagnostic benefit of quantitative analysis in RV single photon emission computed tomography (SPECT) imaging with (99m)Tc-tetrofosmin/sestamibi in patients with RVT. Thirty patients with RVT (15 with idiopathic RVT and 15 with arrhythmogenic right ventricular cardiomyopathy (ARVC)) were compared with 27 control subjects (including 11 with right bundle branch block) with regard to the semiquantitative RV uptake score in each of six segments and the quantitative RV extent score in polar coordinate map displays by SPECT imaging. The RV total score and RV extent score were compared with the RV global function. Perfusion abnormalities were more frequently detected (P = 0.0001) in the ARVC group (59/90, 65.6%) than in the idiopathic RVT group (4/90, 4.4%) or controls (1/162, 0.6%). The RV extent score in the ARVC group (53.0 +/- 24.8) was significantly higher than that in the idiopathic RVT group (8.4 +/- 10.1) or controls (1.2 +/- 4.9). The RV extent score correlated well with the regional RV perfusion score (P < 0.0001) and with the RV ejection fraction (P < 0.0001). Non-invasive RV perfusion mapping using a (99m)Tc-labelled tracer is useful for the quantitative evaluation of RV substrates in patients with ARVC.

Validation of quantitative gated single photon emission computed tomography and an automated scoring system for the assessment of regional left ventricular systolic function

Despite its ability to quantify regional perfusion and function, there is no established method for quantification of regional perfusion and function by myocardial gated single photon emission computed tomography (SPECT). The aim of this study was to establish a quantitative index for regional perfusion and systolic function assessment using gated SPECT. Myocardial SPECT was performed at rest using (99m)Tc sestamibi with 8-frame gating in 62 consecutive patients. In addition to computation of left ventricular ejection fraction (LVEF), a new computerized method for quantifying, displaying and automatically grading regional data was developed. Regional function was quantified as wall motion, regional EF, and imaged based, count based, and normalized per cent wall thickenings (%WTs). Regional perfusion was assessed as a relative per cent peak count. Data were displayed on a 25-segmented polar map and automatically graded with a 5-point scale, and then summed scores were calculated. These quantitative parameters were compared to data from radionuclide ventriculography (RNV) and contrast left ventriculography. Gated SPECT had high reproducibilities for calculating global and regional ejection fractions and %WT indices (r=0.811-0.984, P<0.0001), but measurement of wall motion was less reproducible (r=0.555, SEE=7.9, P<0.011). LVEF estimated by gated SPECT and summed perfusion scores correlated closely (P<0.0001) with angiographic LVEF. Among the summed function indices that correlated closely with LVEF, normalized %WT had the closest correlations with LVEF estimated by RNV (r=0.657, P<0.0001) and by gated SPECT (r=0.778, P<0.0001). Assessment by visual reviewing of cine-mode playback or by normalized %WT had greater overall sensitivity, specificity, and positive and negative predictive values for detecting impaired regional function among the functional parameters: 71%, 79%, 63% and 84% for cine format analysis, and 78%, 73%, 59% and 87% for normalized %WT, respectively. Thus, besides LVEF, quantitative gated SPECT can provide reproducible and reliable quantitative data on regional perfusion and function. Automated summed scores obtained by gated SPECT can reflect integrated abnormalities of regional perfusion and function of the left ventricle. Both visual analyses by cine-mode display and a functional map of normalized wall thickening have greater diagnostic values for detecting regional function deficit related to coronary artery disease.