The Growth Potential and Patency of Free Right Internal Thoracic Arteries Verified by Computed Tomography Angiography

BACKGROUND

The use of the left internal thoracic artery (LITA) is the gold standard in coronary artery bypass graft surgery (CABG). Multiarterial grafting for CABG is being increasingly emphasized. This study aimed to resolve the utility of the right internal thoracic artery (RITA) for multiple CABG as "free" RITA and described new evidence.

METHODS

One hundred sixty-three patients received solo CABG with bilateral internal thoracic arteries between 2005 and 2018. The RITA was used as in situ RITA, group A (n = 62), and the composite graft created with saphenous vein graft (SVG), group B (n = 101). The patency rate and graft size of the composite free RITA and SVG were examined by coronary computed tomography angiography.

RESULTS

The average number of distal anastomoses per patient was 3.4 ± 1.0 in group A, and 4.2 ± 1.1 in group B (P < .001). The sequential grafting with free RITA was in 86 patients. The patency rate of both LITA and RITA was similar in both groups. In group B, 40 patients received late computed tomography angiography at a mean of 46 months (range, 17 to 175). The late patency rate was 95.1% in LITA and 96.9% in free RITA. The diameter of free RITA increased from 2.06 ± 0.34 mm to 2.37 ± 0.23 mm (P = .036); that of in situ LITA increased from 2.08 ± 0.51 mm to 2.44 ± 0.49 mm (P = .047); and that of composite SVG decreased from 4.1 ± 0.9 mm to 2.6 ± 0.7 mm (P < .001).

CONCLUSIONS

Multiple bypass grafting can be sufficiently achieved with LITA and free RITA. The growth potential of free RITA and in situ LITA might play the important role of expected long-term patency.

Minimally Invasive Multiple Coronary Artery Bypass Grafting with Composite Graft Using in situ Right Gastroepiploic and Radial Arteries

Minimally invasive surgery/coronary artery bypass grafting (MICS CABG) via left thoracotomy and multiple CABG is a reported alternative to the standard sternotomy approach. However, harvesting the right internal thoracic artery (RITA) under direct vision requires high surgical skill. We describe MICS CABG with the left internal thoracic artery (LITA) and a composite graft using the in situ right gastroepiploic artery (GEA) and radial artery (RA) to achieve complete coronary revascularization. No complications occurred, and postoperative computed tomography showed patency of all grafts. Our experience suggests that this composite graft can be used safely and effectively in MICS CABG for complete arterial revascularization without difficulty.

Late-Stage Löffler's Endocarditis Mimicking Cardiac Tumor: A Case Report

Löffler's endocarditis (cardiac involvement in hypereosinophilic syndrome) is rare yet life-threatening if left untreated. We describe a case of hypereosinophilic syndrome presenting as a cardiac mass with an abnormal electrocardiogram. Diagnostic studies of the cardiac mass strongly suggested a malignant cardiac tumor invading the papillary muscle. Thus, excision of the cardiac mass and endomyocardial resection with mitral valve replacement were successfully performed. Pathology revealed various stages of thrombosis and irreversible myocardial damage caused by eosinophilic infiltration with no malignancy, leading to the correct diagnosis of late-stage Löffler's endocarditis. The subsequent combination of anticoagulation and corticosteroids was effective with a favorable outcome. This case highlights pitfalls in multimodality imaging of cardiac thrombus and the clinical significance of considering Löffler's endocarditis in the diagnostic work-up of a cardiac mass.

Internet usage and the problems about the commute to school in Japanese adolescents

Introduction

As inappropriate Internet usage has been increasing, various problems were observed, particularly in adolescence. For example, excessive Internet use might lead to absenteeism for high school students. This study aimed to examine the association between Internet usage and some difficulties of commute, such as tardy and absence for school in 4th to 9th-grade students.

Methods

Study participants were all students of the 4th-9th grade in Japanese rural public schools and their parents. In 2018 a self-reported survey was conducted. The questionnaire contained items about Internet usage, such as duration and family rules, and the current situation about commuting to school. The parents answered the same questions about their children and also responded to their own Internet usage time. The answers about their commute to school “tardy more than once a week”, “sometimes absent” and “have experience of school absenteeism” were categorized as “school absence”. The duration of Internet use was categorized every 2 hours as “never”, “0-2hrs (reference) ”, “2-4hrs” and “over 6hrs”. Multiple logistic regression analyses were performed to examine the associations between the duration of Internet use and the absence of school adjusting by covariates.

Results

Study participants were 6,031 students and 5,525 guardians participated, and response rates were 87.8%, and 80.5%, respectively. The number of “school absence” case was 429 (7.2%). The “school absence” was significantly associated with the duration of Internet use, and these relationships grew stronger as the period got longer. Odds ratio and 95% confidence interval of “over 6hrs” were 4.1 and 2.9-5.6, respectively. The parents’ own Internet usage time was also associated with their children’s school absence.

Conclusions

The longer students used the Internet, the higher the risk of school absence. Own Internet usage time of parents was also associated with children's commuting to school.

Key messages

Excessive Internet use might induce absenteeism in younger adolescents as well as older adolescents. Few studies have examined the association between Internet use and absenteeism.

Posterior ventricular restoration treatment for heart failure: a review, past, present and future aspects

Congestive heart failure (CHF) is one of the major causes of death and occurs in more than 15,000,000 patients worldwide. The incidence is expected to increase in parallel with the aging population. Most current therapies for CHF are medications, and biventricular pacing implantation as appropriated by cardiologists, or surgical interventions. The heart transplantation for indicated patients is still gold standard surgery although the 10-year survival rate is approximately 60% based on the worldwide data. However, the cardiac transplantation remains epidemiologically insignificant because of donor pool limitations. New strategies for treating CHF are needed. In addition to conventional cardiac surgery, surgical ventricular restoration was reported as a promising surgical therapy in 1990s. After the first report of partial left ventriculectomy in which posterior wall was widely resected for dilated heart, many controversial clinical and animal research studies have been reported. In this review, the principles of posterior cardiac restoration therapy will be discussed. An overview of posterior cardiac restoration, structure, and torsion are presented. By understanding the structure of cardiac muscle, shape, and torsion of left ventricle for surgical restoration, the procedure can be performed based on appropriate indication and this knowledge can be used to optimize and improve its efficacy. The use of mechanical support devices has recently become commonplace in many centers, and the use of implantable ventricular assist devices as destination therapy will increase. Surgeons will be able to select several options of the treatment for CHF by understanding the advantages and disadvantages of those surgical treatments.

Liver-related safety assessment of green tea extracts in humans: a systematic review of randomized controlled trials

There remain liver-related safety concerns, regarding potential hepatotoxicity in humans, induced by green tea intake, despite being supposedly beneficial. Although many randomized controlled trials (RCTs) of green tea extracts have been reported in the literature, the systematic reviews published to date were only based on subjective assessment of case reports. To more objectively examine the liver-related safety of green tea intake, we conducted a systematic review of published RCTs. A systematic literature search was conducted using three databases (PubMed, EMBASE and Cochrane Central Register of Controlled Trials) in December 2013 to identify RCTs of green tea extracts. Data on liver-related adverse events, including laboratory test abnormalities, were abstracted from the identified articles. Methodological quality of RCTs was assessed. After excluding duplicates, 561 titles and abstracts and 119 full-text articles were screened, and finally 34 trials were identified. Of these, liver-related adverse events were reported in four trials; these adverse events involved seven subjects (eight events) in the green tea intervention group and one subject (one event) in the control group. The summary odds ratio, estimated using a meta-analysis method for sparse event data, for intervention compared with placebo was 2.1 (95% confidence interval: 0.5-9.8). The few events reported in both groups were elevations of liver enzymes. Most were mild, and no serious liver-related adverse events were reported. Results of this review, although not conclusive, suggest that liver-related adverse events after intake of green tea extracts are expected to be rare.

Pre-Operative Left Ventricular Torsion, QRS Width/CRT, and Post-Mitral Surgery Outcomes in Patients With Nonischemic, Chronic, Severe Secondary Mitral Regurgitation

The selection of appropriate candidates for mitral surgery among symptomatic patients with nonischemic, chronic, secondary severe mitral regurgitation (NICSMR) remains a clinical challenge. We studied 50 consecutive symptomatic NICSMR patients for a median follow-up of 2.5 years after mitral surgery and concluded that the pre-operative 2-dimensional speckle tracking echocardiography-derived left ventricular torsional profile and QRS width/cardiac resynchronization therapy are potentially important prognostic indicators for post-surgery survival and reverse remodeling.

•

Determining which patients with NICSMR will benefit from MS is a clinical dilemma.

•

LV torsion (which is a shear strain, not volume strain such as ejection fraction and originates in LV myocardial architectures) may reveal the myopathic conditions and reflect intra-LV electrical conduction.

•

The LV torsional profile predicted post-MS outcomes in NICSMR patients with a narrow QRS but not in those with a wide QRS.

•

The findings may help to resolve the clinical dilemma and identify appropriate candidates for mitral surgery (and other resources) in patients with NICSMR.

Mid-term results of mitral valve palsty in patients with mitral sclerotic lesion

Background

Mitral valve repair is preferred over prosthetic replacement. We surgically repaired mitral valve with degenerated sclerotic lesion and demonstrated mid-term results.

Methods

Mitral valve plasty (MVP) was performed with several procedures including ring annuloplasty, leaflet slicing and decalcification.

Results

There were 19 males and 19 females with a mean age of 67 ± 12 y.o (n = 38). All patients were successfully treated MVP except one case with unrepairable injuries of the thin leaflet. In patients underwent MVP (n = 37), MVP included ring annuloplasty with a rigid full ring of 32 ± 2 mm (n = 37), leaflet slicing (n = 37), decalcification (n = 15) and artificial chordae (n = 14). Mitral valve area was statistically enlarged by MVP (1.65 ± 0.57 vs 2.51 ± 0.58 cm², p < 0.001). Left atrial diameter was statistically reduced after the operation (55 ± 10 vs 46 ± 9 mm, p < 0.001). Severity of MR and right ventricular systolic pressure (RVSP) were statistically decreased after the operation (MR; 1.8 ± 1.0 vs 0.7 ± 0.9, p < 0.001, RVSP; 38 ± 15 vs 30 ± 9 mm Hg, p < 0.001). There were 4 cases with residual MR (Grade II, n = 3; Grade III, n = 1). The 30-days mortality was 0 %. There was one late death due to non-cardiogenic cause (the 3-year survival rate of 97 %) and no redo case due to deterioration of the mitral valve during follow-up period of 21 ± 13 months.

Conclusions

Successful mid-term survival and freedom from reoperation might expect to the durability of MVP in patients with mitral sclerotic lesion.

Post-Thoracic Endovascular Aortic Repair Complicated with Mycotic Aneurysm Rupture, Repaired by Redo Thoracic Endovascular Aortic Repair

Mycotic aneurysms although rare can be devastating. We encountered a dialysis patient with rapidly expanding distal aortic arch aneurysm who underwent axilloaxillary bypass and thoracic endovascular aortic repair (TEVAR). Three months later, he suffered mycotic aneurysm rupture for which redo TEVAR was performed. Antibiotic therapy was discontinued 16 weeks after the second operation, and renal transplantation was performed 6 months later. Dialysis was discontinued in the patient without infection recurrence.

Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position

PURPOSE

Although pannus overgrowth by itself was not the pathology of structural valve deterioration (SVD), it might be related to reoperation for SVD of the bioprostheses.

METHODS

We retrospectively reviewed patients undergoing reoperation for SVD after implantation of the third-generation Mosaic aortic bioprosthesis and macroscopic appearance of the explanted valves was examined to detect the presence of pannus.

RESULTS

There were 10 patients and the age for the initial aortic valve replacement was 72 ± 10 years old. The duration of durability was 9.9 ± 2.0 years. Deteriorated valve presented stenosis (valvular area of 0.96 ± 0.20 cm(2); pressure gradient of 60 ± 23 mmHg). Coexisting regurgitant flow was detected in two cases. Macroscopically, subvalvular pannus overgrowth was detected in 8 cases (80%). The proportion of overgrowth from the annulus was almost even and pannus overgrowth created subvalvular membrane, which restricted the area especially for each commissure. In contrast, opening and mobility of each leaflet was not severely limited and pannus overgrowth would restrict the area, especially for each commissure. In other two cases with regurgitation, tear of the leaflet on the stent strut was detected and mild calcification of each leaflet restricted opening.

CONCLUSION

In patients with the Mosaic aortic bioprosthesis, pannus overgrowth was the major cause for reoperation.

Preoperative transaortic forward flow: Prediction of surgical outcomes in patients with DCM and mitral regurgitation

BACKGROUND

In patients with dilated cardiomyopathy and mitral regurgitation, preoperative prognostic factors are very important.

METHODS

We hypothesized that preoperative transaortic forward flow might be related to postoperative survival, despite mitral regurgitant volume. We retrospectively evaluated surgical outcomes and echocardiographic parameters, including forward flow through the aortic valve.

RESULTS

Seventy-nine patients (54 males, 25 females; mean age 59 ± 12 years) with dilated cardiomyopathy and mitral regurgitation were divided into two groups according to postoperative outcome: 19 patients in group A suffered cardiac death, 60 in group B survived or died of another cause. In group A, death occurred after 227 ± 116 days, group B patients survived (except one who died of infection) for 505 ± 446 days; p < 0.01. Preoperatively, there was no significant difference in ejection fraction, end-diastolic and end-systolic volume index, mitral regurgitant volume, effective regurgitant orifice area, or right ventricular systolic pressure. Preoperative transaortic forward flow was significantly lower in group A vs. group B (1.57 ± 0.33 vs. 1.81 ± 0.46 L m(-2); p 0.04). In group B, transaortic forward flow was increased significantly before discharge (1.81 ± 0.51 vs. 2.43 ± 0.62 L m(-2); p < 0.01). Ejection fraction was significantly alleviated before discharge (28% ± 9% vs. 23% ± 8%; p < 0.01) and recovered to the preoperative value without repeat dilation of the left ventricle in late follow-up.

CONCLUSIONS

Preoperative transaortic forward flow may be a predictor of survival in patients with dilated cardiomyopathy and mitral regurgitation, irrespective of mitral regurgitant volume.

Prediction of Long-Term Survival in Patients with End-Stage Heart Failure Secondary to Ischemic Heart Disease: Surgical Correction and Volumetric Analysis

PURPOSE

Ischemic heart disease (IHD) may result in lethal conditions such as ischemic cardiomyopathy (ICM) and mitral regurgitation (MR).

METHODS

We hypothesized preoperative LV volume would be highly associated with long-term survival in such patients. We retrospectively evaluated effects of LV end-systolic volume index (LVESVI) on survival.

RESULTS

Patients were divided into two groups according to LVESVI; Group S (n = 19, <100 ml/m(2)), and L (n = 55, >100 ml/m(2)). There were 74 patients (male 61, female 13; 61 ± 10 y.o.). There was no statistical significance in preoperative parameters, including ejection fraction (EF), severity of MR, severity of tricuspid regurgitation (TR), and right ventricular systolic pressure (RVSP). After operation, LVESVI and severity of MR were statistically reduced in both groups. However, EF, severity of TR and RVSP were not statistically alleviated in both groups. In Group S, 5- and 10-year survival rates were 93% and 48%. In Group L, 5- and 10-year survival rates were 50% and 29%. There was a statistical difference in long-term survival between two groups.

CONCLUSIONS

Preoperative LV volume would be one of the risk factors for long-term survival in patients with congestive heart failure secondary to IHD. Careful follow-up and optimal treatment should be recommended before LV dimension becomes too large.

Sublocalization of Cardiac Involvement in Sarcoidosis and Surgical Exclusion in Patients With Congestive Heart Failure

BACKGROUND

In sarcoidosis, cardiac involvement can cause fatal conditions such as left ventricular (LV) dysfunction and rhythm disturbance. We surgically treated critical patients with congestive heart failure due to cardiac sarcoidosis.

METHODS

During 14 years, 384 patients with nonischemic dilated cardiomyopathy were operated. Among them, 14 patients (3.6%) with New York Heart Association (NYHA) class IV (male/female, 3/11; 57 ± 11 years) caused by sarcoidosis underwent surgery (elective/emergent, 12/2). The akinetic lesion, as identified by speckle-tracking echocardiography, was excluded.

RESULTS

Localization of akinetic lesions was achieved in 13 patients (93%). In the short axis, lesional distribution was higher in the anterior (62%) and septal segments (54%) when compared with the posterior (31%) and lateral segments (23%). Along the long axis, regional distribution was higher in the mid (85%) and apical segments (69%) when compared with the basal segment (31%). The main lesions were excluded by septal anterior ventricular exclusion (n = 5), posterior restoration procedure (n = 3), endoventricular circular patch plasty (n = 3), and linear resection (n = 2). Mitral valve surgery included mitral valve plasty (n = 7) and replacement (n = 7). In patients undergoing elective surgery, early results showed that 10 patients survived (83%) and NYHA class improved (6 patients in class II and 4 in class III). Patients who underwent emergent surgery did not survive. The observation period was 55 ± 59 months in survivors. During follow-up, 4 patients died after 42 ± 48 months. The other 5 patients have survived for 71 ± 61 months. The 3- and 5-year survival rates were 65% and 52%, respectively.

CONCLUSIONS

Sarcoidosis can result in sublocalized LV involvement, which can be surgically excluded.

Posterior restoration procedures and the long-term results in indicated patients with dilated cardiomyopathy †

OBJECTIVES

Non-transplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. We performed posterior restoration for dilated akinetic or dyskinetic lesions in patients with DCM and obtained favourable outcomes. The early and long-term results of the procedures are discussed.

METHODS

Between 2005 and 2013, posterior restoration procedures (PRPs) for DCM were electively performed in 58 patients (17 with ischaemic and 41 with non-ischaemic DCM). There were 45 men and 13 women with a mean age of 56 ± 12 years old. The mean preoperative ejection fraction was 24% and the preoperative New York Heart Association functional class was Class III in 24 and Class IV in 34 patients with intravenous inotrope support. Indications for PRPs were determined by using speckle-tracking echocardiography of the posterior region of the left ventricle before surgery (GE ultrasound machine, Vivid 7 or Vivid E9). After cardioplegic arrest, mitral surgery or coronary artery bypass grafting (CABG) was performed and the posterior left ventricular (LV) muscle between bilateral papillary muscles was incised or resected. The LV apex was preserved and cryoablation was applied between the cut edge and the posterior mitral annulus. All patients were followed up by transthoracic echocardiography.

RESULTS

In addition to PRP, mitral surgery was performed in 56 (plasty 51, replacement 5), tricuspid annuloplasty in 21, CABG in 17, cardiac resynchronization therapy in 6 and LV lead implantation in 27 patients. Perioperative intra-aortic balloon pumping was used in 9 patients and there was no hospital mortality. After the operation, 35 patients (60%) improved their functional class to Class I or II. In the late follow-up, there were 14 cardiac deaths (congestive heart failure 10, ventricular arrhythmia 4). The 3- and 8-year survival rates were 77 or 66%, respectively.

CONCLUSIONS

DCM with posterior akinesis or dyskinesis indicated by speckle-tracking echocardiography can be surgically treated with PRP. Our results demonstrated that 60% of the selected patients could avoid heart transplantation with relief of their symptoms.

Tricuspid annuloplasty with the MC3 ring and septal plication technique

BACKGROUND

Functional tricuspid regurgitation is caused by annular dilation mainly in the posterior annulus. However, ring annuloplasty does not always prevent the recurrence of tricuspid regurgitation due to dilation of the septal annulus. We developed a septal plication technique with a 3-dimensional MC3 ring.

METHODS

Between 2006 and 2011, 76 patients (male/female 30/46; mean age 68 ± 11 years) with functional tricuspid regurgitation received tricuspid ring annuloplasty. After placement of the annular sutures, the 3 commissural ring portions were fixed on the equivalent commissures to plicate the anterior and posterior annulus. The end of the septal ring portion was fixed at the optimal annular position to obtain minimal tricuspid regurgitation. All patients were followed-up for a mean of 47 ± 18 months; the longest duration was 79 months.

RESULTS

Although there was no operative death, one patient died of sepsis during hospitalization (hospital mortality 1.3%). After implantation of the MC3 ring (mean size 31.0 ± 3.3 mm), additional edge-to-edge sutures were required for minor leakage in 5 (7%) patients. The degree of tricuspid regurgitation was significantly reduced at discharge (0.5 ± 0.6) and midterm (0.6 ± 0.6) compared to 2.5 ± 0.7 before the operation (p < 0.0001).

CONCLUSIONS

The surgical durability of the MC3 ring was satisfactory at early and midterm follow-up, suggesting that correct plication of the septal annulus is effective for tricuspid ring annuloplasty with a 3-dimensional MC3 ring.

[Effectiveness of tolvaptan for postoperative heart failure in a patient with combined valvular disease and pulmonary hypertension]

We report a case of a 60-year-old man with postoperative congestive heart failure( CHF) successfully treated with tolvaptan. The patient was diagnosed with pulmonary hypertension due to mitral stenosis and regurgitation combined with tricuspid regurgitation. He underwent mitral and tricuspid valvuloplasty. His postoperative course was uneventful until CHF symptoms secondary to volume overload appeared on the 4th day. Congestion with pulmonary hypertension was treated with 0.042 μg/kg/min of intravenous human atrial natriuretic peptide (hANP). His condition improved, and on the 11th postoperative day, he was weaned off hANP;oral administration of 40 mg per day of furosemide was initiated. However, 2 days after discontinuation of intravenous hANP, CHF recurred and serum sodium decreased to 128 mEq/l. Oral tolvaptan 7.5 mg per day was added to the furosemide, and CHF and hyponatremia subsequently improved. In this case, oral tolvaptan was effective for the treatment of refractory CHF with pulmonary hypertension after cardiac surgery.

Posterior restoration of left ventricle and mitral valve repair in patients with muscular dystrophy

BACKGROUND

Congestive heart failure (CHF) is major risk factor for survival among patients with muscular dystrophy (MD). The degenerative postero-lateral wall of the left ventricle (LV), which results in systolic dysfunction and functional mitral regurgitation (MR) at the time of CHF, is not well described in MD.

METHODS

We restored the LV and repaired the mitral valves of 6 patients (mean age, 43 ± 9 years) during emergency and elective procedures. Two and 4 patients were in New York Heart Association (NYHA) functional classes III and IV, respectively. One patient required emergency preoperative intraaortic balloon pump support. Before operation, speckle-tracking echocardiography was applied to detect the myocardial lesion. The postero-lateral LV wall that is critically affected in MD was excluded during posterior restoration. Functional MR was repaired using a combination of ring annuloplasty, papillary muscle approximation, and chordal cutting. The LV myocardium between the end of the LV incision line and the mitral annulus was cryoablated to prevent late ventricular arrhythmia.

RESULTS

All patients survived (100%) for a mean follow-up of 59±39 (range; 5 to 101) months. The NYHA functional classes improved to I and II (n=3 each). Left ventricular end-diastolic diameter significantly decreased from 77±13 to 59±4 mm (p=0.0088), whereas ejection fraction did not significantly improve (0.24±0.1 vs 0.29±0.11, p=0.2451), although MR severity was significantly eliminated (3.5±0.5 vs 0.5±0.6, p=0.0003). No cardiac events were associated with CHF or arrhythmia during follow-up.

CONCLUSIONS

Posterior restoration of the LV and mitral repair are useful for treating CHF in patients with MD, and improve survival.

[Management of cardiopulmonary bypass during cardiac surgery for patients with heparin-induced thrombocytopenia]

We experienced 4 cases of open heart surgeries under preoperative diagnosis of heparin-induced thrombocytopenia(HIT). We performed operation with argatroban instead of heparin. The argatroban was administered intravenously with a bolus of 100 μg/kg. After activated clotting time(ACT)reached over 200 seconds, continuous infusion of argatroban was started, 1~2 μg/kg/min until the level of ACT over 250 in the case of off-pump coronary artery bypass grafting(OPCAB), with 6~10 μg/kg/min, or the level of ACT over 400 with the use of cardiopulmonary bypass (CPB). All cases required more than 60 minutes to achieve the target ACT level after starting the argatroban. In 1 case it was impossible to achieve target level of ACT by argatroban alone, and heparin was used concomitantly. In 1 case there was a complication of membrane occlusion of CPB. Open cardiac surgery with the use of argatroban required specific care for coagulation to complete operation.

Impact of left ventricular remodelling on outcomes after left ventriculoplasty for ischaemic cardiomyopathy: Japanese surgical ventricular reconstruction group experience

OBJECTIVES

Surgical ventricular reconstruction (SVR) for patients with severe left ventricular (LV) remodelling due to ischaemic cardiomyopathy is still controversial, because the Surgical Treatment for Ischaemic Heart Failure (STICH) trial demonstrated that SVR not only has no beneficial effect on survival compared with coronary artery bypass grafting (CABG) alone, but also is worse for those with a larger LV. Therefore, we assessed the impact of LV remodelling on the outcomes after SVR for ischaemic cardiomyopathy in Japan, using Di Donato's LV shape classification.

METHODS

From 2000 to 2010, 627 patients underwent SVR for ischaemic heart failure in 11 Japanese hospitals. To assess the patients with an LV ejection fraction (LVEF) of ≤ 35% like the STICH trial, considering the severity of LV remodelling, the patients with a preoperative LVEF of >35%, no preoperative LV volume assessment and no preoperative LV shape classification were excluded. Finally, 323 patients were selected as the study subjects. The LV shape was divided into three types according to Di Donato's classification. Types 1 and 3 indicate the aneurysmal and globally akinetic LV, respectively. Type 2 is the intermediate shape.

RESULTS

Type 1, 2 and 3 LV shapes were observed in 85 (26%), 104 (32%) and 134 (42%) of the patients, respectively. The preoperative LV volume and diameter increased if the LV became more akinetic (Type 3 > 2 > 1, P < 0.001). LVEF was lower in those with more akinetic LV (P = 0.002). The preoperative LV end-diastolic volume index and LVEF in Type 3 patients were 133 ± 47 ml/m(2) and 22 ± 7%, respectively. Mitral valve repair was more frequently performed for patients with the Type 3 LV shape (65%) than for the others (P < 0.001). The hospital mortality rates were 2.4, 2.9 and 7.4% for Type 1, 2 and 3 patients, respectively (P = 0.16). Kaplan-Meier analysis demonstrated no significant difference in mortality among the three groups (log-rank P = 0.37). The 5-year survival rates were 81, 70 and 73% for Type 1, 2 and 3 patients, respectively.

CONCLUSIONS

The severity of LV remodelling did not affect survival after SVR plus CABG. The results of SVR were acceptable even for those with globally akinetic LV due to ischaemic cardiomyopathy.

[Redo coronary artery bypass grafting after pneumonectomy]

A 77-year-old man who had undergone left pneumonectomy 16 years and quadruple coronary artery bypass grafting (CABG) 4 years previously presented with unstable angina pectoris. Coronary angiography revealed severe stenosis of the left main trunk and the proximal left anterior descending artery(LAD), and the severely narrowed left internal thoracic artery (LITA)-LAD graft. Computed tomography(CT) presented a marked shift of the heart and great vessels into the left hemithorax with a hyperinflated right lung crossing the midline. The LAD would not seem to be accessible by median sternotomy. Off-pump coronary artery bypass grafting (OPCAB) with a saphenous vein graft to LAD was performed through a rib-cross left thoracotomy. The patient's postoperative course was uneventful, and postoperative CT revealed a patent graft. OPCAB through rib-cross thoracotomy is safe and useful and can be an option for redo CABG, particularly in instances of previous pneumonectomy.

[Acute Type A aortic dissection with superior mesenteric arterial dissection; report of a case]

We report a case of acute type A dissection with acute abdomen due to blood flow insufficiency in the superior mesenteric artery. A 73-year-old man was presented to hospital complaining sudden onset of chest pain. Contrast-enhanced computed tomography revealed a type A aortic dissection, that extended from the ascending aorta to the left common iliac atery. Superior mesenteric artery was compressed by the thrombosed false lumen. Epigastric pain was exacerbated acutely, we decided to treat the bowel ischemia 1st, and after that, if bowel ischemia was reversible, central repair operation performed. Emergent saphenous vein bypass was performed from the right external iliac artery to the superior mesenteric artery. Then total arch replacement was performed using cardiopulmonary bypass. The patient complicated with postoperative paralytic ileus, he completely recovered without bowel resection.

[Preserving autologous heart operation for dilated cardiomyopathy]

OBJECTIVE

We report non transplant surgical procedure (preserving autologous heart operation) for the patients with dilated cardiomyopathy( DCM), clinical outcomes, and the factor of predict prognosis.

PATIENT AND METHOD

Since May 2000, 258 patients received surgical procedure for 11 years.

SURGICAL PROCEDURES

We performed mitral surgery (plasty or replacement) for the patients with more than mild mitral regurgitation (MR). We performed papirally muscule plication since 2005, and we performed 2nd chordal cutting since 2008, for the patients with MR due to mitral tethering. The surgical left ventricular reconstruction( SVR) was performed for the patients with dilated left ventricular. We use spackle tracking echocardiography to decide the type of SVR since 2008.

RESULT

Hospital death was 18.2%, and late cardiac death was 27.5%.Almost the cause of death was congestive heart failure and ventricular arrhythmia. Five years survival was 58%, 10 years survival was 39%. Preoperative condition, emergent operation, inotropic support, intra aortic balloon pumping(IABP),affect the prognosis. But left ventricular size did not affect it.

CONCLUSION

Surgical treatment for the patient with DCM should be performed with stable preoperative condition.

[Non-occlusive mesenteric ischemia after off-pump coronary artery bypass grafting]

Non-occlusive mesenteric ischemia( NOMI) after cardiac surgery is a rare but catastrophic complication. Although NOMI is generally recognized to be associated with extracorporeal circulation, we present a fatal case of a patient who developed NOMI after off-pump coronary artery bypass grafting (OPCAB). An 85-year-old man with left main trunk and triple vessel disease underwent OPCAB. He developed severe abdominal pain with metabolic acidosis 9 hours postoperatively. Selective angiography of the superior mesenteric artery( SMA) showed narrow and spastic branches of the SMA. A continuous intra-arterial perfusion with papaverine was started, but he died of multiple organ failure on the 3rd postoperative day. We emphasize the importance of early diagnosis and adequate treatment of NOMI including prompt exploratory laparotomy.

[Preserving autologous heart operation for ischemic cardiomyopathy]

OBJECTIVE

We report our surgical procedure (preserving autologous heart operation) for the patients with ischemic cardiomyopathy (ICM), and the results.

PATIENT AND METHOD

Since May 2000, 212 patients received surgical procedure for ten years.

SURGICAL PROCEDURES

We performed complete coronary artery bypass grafting (CABG), mitral surgery (plasty or replacement) for the patients with more than mild mitral regurgitation. We performed papirally muscle plication since 2005, and we performed 2nd chordal cutting since 2008, for the patients with mitral regurgitation (MR) due to severe mitral tethering. The surgical left ventricular reconstruction (SVR) was performed for the patients with dilated left ventricular. We use speckle tracking echocardiography to decide the type of the procedure of surgical left ventricular reconstruction since 2008.

RESULT

Hospital death was 8.0%, and late death was 9.9%. Almost of the cause of death was congestive heart failure and ventricular arrhythmia. Five years survival was 78%, 10 years survival was 73%.

CONCLUSION

The non transplant surgery for the patient with ICM was effective with the combination of CABG, mitral valve plasty (MVP) or mitral valve replacement (MVR), SVR. The size of left ventricle (LV) after SVR seemed to be a factor for late outcome of the surgery.

[Repented Bentall operation for the case of aortitis with totally calcified ascending aortic allograft]

A 49-year-old male underwent re-do root Bentall operation with aortic allograft for the prosthetic valve detouchment due to aortitis syndrome 15 years ago (reported in 1998). He was presented with the hemolytic anemia due to severe aortic stenosis. The totally calcified aortic allograft was found by the computed tomography and chest X-ray. The allograft severely migrated to the sternum was approached by re-sternotomy under the circulatory arrest following the establishment of cardiopulmonary circulation and the 2nd-re-operation of root replacement was performed with composite graft with mechanical heart valve. He was discharged on foot on the 46th postoperative day. A tight follow-up is necessary for such a case of aortitis syndrome.

[Redo-operation for the cusp perforation 5 years after aortic valve replacement with stentless bioprosthesis; report of a case]

A 31-year-old male presented with increase of aortic valve regurgitation 5 years after implantation of Prima Plus Stentless bioprosthesis in a bicuspid aortic valve. He underwent redo aortic valve replacement with a mechanical valve concomitant with replacement of the ascending aorta. Pathological examination of the explanted stentless valve presented no inflammatory cell infiltration. The prosthetic valve regurgitation was considered to be due to small injury at the 1st operation.

Ablation of C/EBP homologous protein attenuates endoplasmic reticulum-mediated apoptosis and cardiac dysfunction induced by pressure overload

BACKGROUND

Apoptosis may contribute to the development of heart failure, but the role of apoptotic signaling initiated by the endoplasmic reticulum in this condition has not been well clarified.

METHODS AND RESULTS

In myocardial samples from patients with heart failure, quantitative real-time polymerase chain reaction revealed an increase in messenger RNA for C/EBP homologous protein (CHOP), a transcriptional factor that mediates endoplasmic reticulum-initiated apoptotic cell death. We performed transverse aortic constriction or sham operation on wild-type (WT) and CHOP-deficient mice. The CHOP-deficient mice showed less cardiac hypertrophy, fibrosis, and cardiac dysfunction compared with WT mice at 4 weeks after transverse aortic constriction, although the contractility of isolated cardiomyocytes from CHOP-deficient mice was not significantly different from that in the WT mice. In the hearts of CHOP-deficient mice, phosphorylation of eukaryotic translation initiation factor 2alpha, which may reduce protein translation, was enhanced compared with WT mice. In the hearts of WT mice, CHOP-increased apoptotic cell death with activation of caspase-3 was observed at 4 weeks after transverse aortic constriction. In contrast, CHOP-deficient mice had less apoptotic cell death and lower caspase-3 activation at 4 weeks after transverse aortic constriction. Furthermore, the Bcl2/Bax ratio was decreased in WT mice, whereas this change was significantly blunted in CHOP-deficient mice. Real-time polymerase chain reaction microarray analysis revealed that CHOP could regulate several Bcl2 family members in failing hearts.

CONCLUSIONS

We propose the novel concept that CHOP, which may modify protein translation and mediate endoplasmic reticulum-initiated apoptotic cell death, contributes to development of cardiac hypertrophy and failure induced by pressure overload.

[Saphenous vein graft aneurysm after coronary artery bypass grafting surgery presenting with chronic heart failure]

An 82-year-old woman with a history of a coronary artery bypass grafting (CABG) 10 years prior was admitted because of general fatigue, appetite loss and systemic edema. She presented with a right pericardial mass on chest radiography. Echocardiogram and computed tomography (CT) revealed a 6.0 x 7.0 cm saphenous vein graft aneurysm (SVGA) compressing both right atrium and the right ventricle. She was successfully treated with the aneurysmal resection and postoperative course was uneventful. Although SVGA is an unusual complication after CABG, we recommend that any patient with a history of previous CABG who presents with a mediastinal mass should be evaluated for possibility of SVGA.

[Surgical treatment for atrial fibrillation using ablation devices and ablation of autonomic ganglion plexi]

BACKGROUND

Development of ablation device for the surgical treatment for atrial fibrillation (Af) has suggested the safety and easiness of the maze procedure. However, the success rate of sinus rhythm (SR) recovery is not satisfactory. We studied the maze procedure and the results with ablation device and also with additional ganglion plexi (GP) ablation.

PATIENTS AND METHODS

Since April in 2002, 269 patients received maze operation with ablation device. The etiology was valvular disease in 196, ischemic heart disease in 18, dilated cardiomyopathy (DCM) in 36, and others in 19. The full maze operation with ablation devices and cryoablation was performed in principle and monopolar ablation devices were used in early phase and the bipolar ablation device was applied thereafter. The 73 patients after October in 2007 were divided into 44 patients with simultaneous GP ablation and 29 patients without GP ablation and the recovery rate of SR was compared in the 2 groups.

RESULTS

There were 7 hospital deaths (5 in DCM and 2 in valve disease). After the operation, 79% of the patients with monopolar devices and 75% of the patients with bipolar device were in SR. Among them, 88% of the patients with simultaneous GP ablation were in SR and no major complication.

CONCLUSION

The full maze operation with bipolar ablation and cryoablation showed minimal operative risk and concomitant GP ablation improved the SR recovery rate after the operation.

X-box binding protein 1 regulates brain natriuretic peptide through a novel AP1/CRE-like element in cardiomyocytes

The unfolded protein response (UPR) is triggered to assist protein folding when endoplasmic reticulum (ER) function is impaired. Recent studies demonstrated that ER stress can also induce cell-specific genes. In this study, we examined whether X-box binding protein 1 (XBP1), a major UPR-linked transcriptional factor, regulates the expression of brain natriuretic peptide (BNP) in cardiomyocytes. In samples from failing human hearts, extensive splicing of XBP1 was observed along with increased expression of glucose-regulated protein of 78 kDa (GRP78), a target of spliced XBP1 (sXBP1), suggesting that the UPR was induced in heart failure in humans. Interestingly, quantitative real-time PCR revealed a positive correlation between cardiac expression of GRP78 and BNP, leading us to test the hypothesis that sXBP1 regulates BNP as well as GRP78 in cardiomyocytes. A pharmacological ER stressor caused a dose-dependent increase in the expression of sXBP1 and BNP by cultured cardiomyocytes. Short interfering RNA targeting XBP1 suppressed the induction of BNP expression by a pharmacological ER stressor or norepinephrine, which was rescued by the adenovirus-mediated overexpression of sXBP1. The promoter assay with overexpression of sXBP1 or norepinephrine showed that the proximal AP1/CRE-like element in the promoter region of BNP was critical for transcriptional regulation of BNP by sXBP1. Direct binding of sXBP1 to this element was confirmed by the chromatin immunoprecipitation assay. These findings suggest that ER stress observed in failing hearts regulates cardiac BNP expression through a novel promoter region of the AP1/CRE-like element.

Identification of genes related to heart failure using global gene expression profiling of human failing myocardium

Although various management methods have been developed for heart failure, it is necessary to investigate the diagnostic or therapeutic targets of heart failure. Accordingly, we have developed different approaches for managing heart failure by using conventional microarray analyses. We analyzed gene expression profiles of myocardial samples from 12 patients with heart failure and constructed datasets of heart failure-associated genes using clinical parameters such as pulmonary artery pressure (PAP) and ejection fraction (EF). From these 12 genes, we selected four genes with high expression levels in the heart, and examined their novelty by performing a literature-based search. In addition, we included four G-protein-coupled receptor (GPCR)-encoding genes, three enzyme-encoding genes, and one ion-channel protein-encoding gene to identify a drug target for heart failure using in silico microarray database. After the in vitro functional screening using adenovirus transfections of 12 genes into rat cardiomyocytes, we generated gene-targeting mice of five candidate genes, namely, MYLK3, GPR37L1, GPR35, MMP23, and NBC1. The results revealed that systolic blood pressure differed significantly between GPR35-KO and GPR35-WT mice as well as between GPR37L1-Tg and GPR37L1-KO mice. Further, the heart weight/body weight ratio between MYLK3-Tg and MYLK3-WT mice and between GPR37L1-Tg and GPR37L1-KO mice differed significantly. Hence, microarray analysis combined with clinical parameters can be an effective method to identify novel therapeutic targets for the prevention or management of heart failure.

Surgical treatment for heart failure: left ventricular restoration for cardiomyopathy

Congestive heart failure has become a major problem and the only surgical treatment for end-stage heart failure caused by dilated cardiomyopathy (DCM) had been heart transplantation. However, because of the shortage of donors, several procedures for non-transplant surgery have been developed. Published literature on left ventricular (LV) restoration was searched to review the new surgical procedures for treating patients with ischemic or non-ischemic DCM. LV restoration was initiated in the 1980s for repairing LV aneurysm. In the 1990s several surgical procedures were introduced for treating DCM, and the new evolving surgical treatment plays an important role in the management of DCM in the 21st century.