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Objective: In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting., Methods: We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors., Results: The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P  = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P  = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P  = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P  < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P  = .05) than the incomplete revascularization group., Conclusions: In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible., (© 2023 The Author(s).)

The small GTPase Rab8 plays a vital role in the vesicular trafficking of cargo proteins from the trans- Golgi network to target membranes. Upon reaching its target destination, Rab8 is released from the vesicular membrane into the cytoplasm via guanosine triphosphate (GTP) hydrolysis. The fate of GDP-bound Rab8 released from the destination membranes, however, has not been investigated adequately. In this study, we found that GDP-bound Rab8 subfamily proteins are targeted for immediate degradation, and the pre-emptive quality control machinery is responsible for eliminating these proteins in a nucleotide-specific manner. We provide evidence that components of this quality control machinery have a critical role in vesicular trafficking events, including the formation of primary cilia, a process regulated by the Rab8 subfamily. These results suggest that the protein degradation machinery plays a critical role in the integrity of membrane trafficking by limiting the excessive accumulation of GDP-bound Rab8 subfamily proteins., Competing Interests: The authors declare that there are no competing commercial interests in relation to this work., (© 2023 The Author(s).)

Cardiac calcified amorphous tumors are rare non-neoplastic intracavitary masses with unknown cause. A 60-year-old man presented with sustained ventricular tachycardia. Transthoracic echocardiography and contrast-enhanced angio-computed tomography demonstrated an expanding 73 × 40 mm sized calcified mass in the left ventricle. He underwent successful total removal of the mass and cryo-ablation at the normal myocardial border. Histopathological examination confirmed a diagnosis of cardiac calcified amorphous tumors. The postoperative course was uneventful, without ventricular tachycardia recurrence. To our knowledge, this is the first reported case of confirmed cardiac calcified amorphous tumors causing ventricular tachycardia and treated by surgical resection combined with cryo-ablation.

Background: Consensus regarding an optimal atrial fibrillation (AF) ablation lesion set concomitant with aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) has not been established., Methods: We enrolled 125 consecutive patients (89 men; 70 ± 8 years old) with persistent AF who underwent radiofrequency-based pulmonary vein isolation (PVI) (PVI group, n = 53) or a Cox-Maze procedure (Maze group, n = 72) with AVR and/or CABG. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent Cox-Maze with and those who underwent PVI, we established weighted Cox proportional-hazards regression models with inverse probability of treatment weighting. Mean follow-up was 63 ± 34 months (maximum, 154 months)., Results: There was 1 in-hospital death in each group. Patients who underwent Cox-Maze showed a higher freedom from AF at all follow-up examinations. After the operation, there were 32 deaths, 13 thromboembolisms, 8 hemorrhagic events, and 22 heart failure readmissions. The Maze group had higher rates for 5-year survival (88% vs 64%, P = .013) and freedom from composite events (74% vs 42%, P < .001). After adjustment with inverse probability of treatment weighting, the Cox-Maze procedure still showed a lower risk of overall mortality (adjusted hazard ratio, 0.38; 95% confidence interval, 0.21-0.66; P = .001) and composite adverse events (adjusted hazard ratio, 0.52; 95% confidence interval, 0.35-0.76; P = .001)., Conclusions: In patients with persistent AF indicated for nonmitral valve surgery, a concomitant Cox-Maze procedure resulted in superior AF- and event-free survival compared with PVI, without increased risk of early mortality. These findings may assist decision making for surgical management of persistent AF concomitant with AVR and/or CABG., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown., Methods and results: Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024)., Conclusions: NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.

Objectives: This retrospective study aimed to clarify the incidence, determinants and clinical impact of left ventricular (LV) function non-recovery after coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy., Methods: A total of 490 patients with ischaemic cardiomyopathy (LV ejection fraction ≤ 40%) undergoing CABG were analysed. Follow-up echocardiography was performed at 1 month, 1 year, and annually thereafter. LV function recovery was defined as ejection fraction (EF) ≥40% at least once during follow-up. LV function non-recovery was defined as EF <40% at any follow-up. The primary and secondary end points were changes in LV function and all-cause mortality, respectively. Clinical follow-up was completed in 461 patients (94.1%; mean follow-up: 64.5 ± 45.5 months)., Results: During follow-up, echocardiographic assessments were performed 1863 times (mean, 3.8 ± 2.4), and 193 patients (39.4%) exhibiting LV function non-recovery were identified. Overall survival was significantly higher in the recovery group (53.9%) than in the non-recovery group (31.4%) at 10 years (P < 0.001). Independent predictors of LV function non-recovery were preoperative LV end-systolic diameter [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04-1.10; P < 0.001] and bilateral internal thoracic artery grafting (OR 0.61, 95% CI 0.39-0.95; P = 0.028). In a multivariable Cox proportional hazards model, LV function non-recovery was significantly associated with all-cause mortality (hazard ratio 2.14, 95% CI 1.60-2.86; P < 0.001)., Conclusions: Almost 40% of patients with ischaemic cardiomyopathy undergoing CABG did not achieve LV function recovery and were associated with poor prognosis. To achieve LV function recovery, CABG with bilateral internal thoracic artery may be recommended before excessive LV remodelling occurs., Clinical Trial Registration Number: Institutional review board of Osaka University Hospital, number 16105., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A reproducible swine thoracic aortic aneurysm (TAA) model is useful for investigating new therapeutic interventions. We report a surgical method for creating a reproducible swine saccular TAA model. We used eight female swine weighing 20-25 kg (LWD; ternary species). All procedures were performed under general anesthesia and involved left thoracotomy. Following aortic cross-clamping, the thoracic aorta was surgically dissected and the media and intima were resected, and the dissection plane was extended by spreading the outer layer for aneurysmal space. Subsequently, only the adventitial layer of the aorta was sutured. At 2 weeks after these procedures, angiography and computed tomography were performed. After follow-up imaging, the model animals were euthanized. Macroscopic, histological, and immunohistological examinations were performed. All model animals survived, and a saccular TAA was confirmed by follow-up imaging in all cases. The mean length of the shorter and the longer aortic diameter after the procedure were 14.01 ± 1.0 mm and 18.35 ± 1.4 mm, respectively (P<0.001). The rate of increase in the aortic diameter was 131.7 ± 13.8%, and the mean length of aneurysmal change at thoracic aorta was 22.4 ± 1.9 mm. Histological examination revealed intimal tears and defects of elastic fibers in the media. Immunostaining revealed MMP-2 and MMP-9 expressions at the aneurysm site. We report our surgical method for creating a swine saccular TAA model. Our model animal may be useful to investigate new therapeutic interventions for aortic disease.

Aims: In patients with ischaemic mitral regurgitation (MR), the impact of mitral valve surgery with concomitant coronary artery bypass grafting (CABG) on post-operative survival and left ventricular (LV) reverse remodelling remains unknown. Therefore, we investigated these outcomes following restrictive mitral annuloplasty (RMA) with and without CABG in those patients., Methods and Results: This study included 309 patients with chronic MR and ischaemic cardiomyopathy for whom concomitant CABG was indicated (n = 225) or not indicated (n = 84) with RMA. The primary endpoint was all cause mortality during the follow-up, and the secondary endpoint was defined as the composite of mortality and re-admission for heart failure. Linear mixed model was used to analyse serial echocardiographic changes in LV function. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent RMA with and those who underwent it without CABG, we established weighted Cox proportional-hazards regression models with inverse-probability-of-treatment weighting. Pre-operatively, there were no intergroup differences in age (RMA with CABG, 67 ± 9 vs. RMA without CABG, 68 ± 11, P = 0.409) and logistic EuroSCORE II (16 ± 14 vs. 15 ± 15%, P = 0.496). The 30-day mortalities were 2.7% and 3.6%, respectively (P = 0.67). During follow-up with a mean duration of 72 ± 37 months (range, 5.6-179), there were 157 deaths and 105 re-admissions for heart failure. Overall 1-year and 5-year survival rates were 83 ± 2% and 58 ± 3%, respectively. Patients who did not receive CABG with RMA had a significantly lower 5-year survival rate (45% vs. 63%, P = 0.049) and freedom from adverse events defined as mortality and/or admission for heart failure (19% vs. 43%, P < 0.001) than those who did. After adjustments for clinical covariates with inverse-probability-of-treatment weighting, concomitant CABG was identified as an independent protective factor for adverse events (hazard ratio: 0.53; 95% confidence interval: 0.44-0.64; P < 0.001). Along with significant MR reduction, LV function parameters changed over time after surgery in both groups, with greater improvements in patients who underwent RMA with CABG (time effect, P < 0.001; and interaction effect, P = 0.002)., Conclusions: RMA can be performed with an acceptable operative mortality, irrespective of indications for CABG. Patients with ischaemic MR for whom CABG is indicated with RMA are more likely to show better long-term and event-free survival and greater improvements in LV systolic function. The optimal revascularization strategy should be discussed with a heart team whenever indicated in patients with ischaemic MR; otherwise, they may miss the opportunity to benefit from concomitant CABG during subsequent RMA., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: Non-obstructive general angioscopy is a powerful modality for detecting areas in the aorta with vulnerable plaque, which are difficult to visualize using conventional diagnostic tools such as computed tomography (CT). The aim of the present study was to clarify the efficacy and usefulness of aortic angioscopy in patients with chronic type B aortic dissection scheduled for thoracic endovascular repair (TEVAR)., Methods: Ten patients with chronic type B aortic dissection who underwent elective TEVAR were enrolled. Before starting the stent graft procedure, the aortic intima was observed by use of non-obstructive general angioscopy. Based on those findings, the range of the stent graft position was confirmed., Results: In all patients, observations of the aortic intima with non-obstructive general angioscopy from a point just proximal of the descending aorta to the iliac artery were successful. At the proximal site, an entry site or ulcer-like projection was detected in all patients, while a small intimal tear or entry, or an irregular intima surface with a salmon-pink color were seen in some cases. In contrast, preoperative CT did not detect any such findings in the same locations. After confirming the position of the abnormal intima, we determined the position of the distal end of the stent graft. No complications considered to be related to aortic angioscopy were noted., Conclusions: Non-obstructive general angioscopy is useful for observing the condition of the aortic intima, revealing abnormal conditions, and confirming a normal aortic intima in patients with chronic type B aortic dissection. This modality may play an important role in determining the precise position of a stent graft for a TEVAR procedure., (Copyright © 2020. Published by Elsevier Ltd.)

Objectives: Infective endocarditis (IE) is a critical infection with a high mortality rate, and it usually causes sepsis. Though disseminated intravascular coagulation (DIC) sometimes occurs in IE patients, no definitive treatment strategy for IE patients with DIC as a complication exists. Therefore, we evaluated the prevalence, surgical results and treatment strategy for IE complicated with DIC., Methods: Between 2009 and 2017, a total of 585 patients undergoing valve surgery for active IE were enrolled at 14 institutions, of whom 116 (20%) had DIC as a complication. For further evaluation, we divided DIC patients into medical treatment-first (n = 45, group M) and valve surgery-first (n = 51, group S) groups after excluding 20 patients with intracranial haemorrhage., Results: The overall survival rates at 1 and 5 years were 91% and 85% in the non-DIC group and 65% and 55% in the DIC group, respectively (P < 0.001). Recurrence-free survival rates at 1 and 5 years were 99% and 95% in the non-DIC group and 94% and 74% in the DIC group, respectively (P < 0.001). The overall survival rates at 1 and 5 years were 77% and 64% in group S and 51% and 46% in group M, respectively (P = 0.032). Multivariable analysis revealed that 'medical treatment first' was an exclusive independent risk factor [hazards ratio 2.26 (1.13-4.75), P = 0.024] for overall mortality., Conclusions: Mortality and IE recurrence were statistically significantly higher in DIC patients. Valve surgery should not be delayed because most patients proceeding with medical treatment eventually require emergency surgery and their clinical outcomes are worse than those of patients undergoing early surgery., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: A successful endovascular treatment for acute type A dissection has been recently reported. However, there has been no consensus regarding the appropriate stent graft size based on the estimated predissected aortic diameter for this pathology., Methods: We developed new equations for estimating the predissected ascending aorta and aortic arch by investigating computed tomography images that had been scanned less than 3 years before dissection. From 684 patients with type A AAD, 28 were matched for the study. We measured the predissected whole circumference length (pre-wCL), postdissected whole circumference length (post-wCL), postdissected true lumen circumference length (post-tCL), postdissected major diameter (post-Dma), and postdissected minor diameter (post-Dmi) of the acutely dissected aorta. This was followed by the calculation of (post-tCL + post-wCL)/2 and (post-Dma + post-Dmi)/2. Six equations (linear function) and modified equations were derived from each of the abovementioned parameters., Results: Four equations (post-wCL, post-Dma, [post-tCL + post-wCL]/2, and [post-Dma + post-Dmi]/2) had nearly the same bias and accuracy (<9.42 mm). For clinical use, we also developed one modified equation using the post-wCL (y = 0.9x) among four parameters because of its simplicity and decreased the possibility of measurement error. The biases of circumference length and accuracy were 5.5 ± 4.9 mm and 84.6%, respectively, and they improved to 4.4 ± 3.3 mm and 93.4% in cases with a ratio of post-tCL/post-wCL of 0.66 or more., Conclusions: Our newly developed equation can be used to calculate the predissected ascending aortic diameter and aortic arch diameter in cases of acute type A dissection., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although minimally invasive mitral valve surgery via a right minithoracotomy (MICS-mitral) is widely performed, no tool to evaluate its risk has been reported. We sought to establish MICS-mitral risk calculators using a national clinical database for selection of appropriate patients., Methods and results: Between 2008 and 2015, 3,240 patients (mean age 59±14 years, males 1,950) underwent a MICS-mitral procedure in Japan and were registered in a national clinical database. We examined mortality and composite outcome (operative mortality, stroke, reoperation for bleeding) using multivariate analysis, then developed a risk calculator for each using stepwise analysis. Operative mortality was 1.1% and the composite outcome rate was 5%. In multivariate analysis, risk factors for operative mortality were shown to be age, respiratory dysfunction, thoracic aortic disease, myocardial infarction, body mass index >30, NYHA class IV, moderate or severe aortic regurgitation, mitral valve replacement, multiple valve surgery, and annual cases <10. ROC curve analysis of our prediction formulas for mortality and composite outcome revealed an area under the curve for operative mortality of 0.877 (95% confidence interval: 0.82-0.94, P<0.01) and for composite outcome of 0.665 (95% confidence interval: 0.62-0.71, P<0.01)., Conclusions: We developed risk calculator formulas using risk factors associated with both operative mortality and composite outcome. The present risk calculator formula is useful for patient selection and may influence future applications for this procedure.

Rab family small GTPases are master regulators of distinct steps of intracellular vesicle trafficking in eukaryotic cells. GDP-bound cytoplasmic forms of Rab proteins are prone to aggregation due to the exposure of hydrophobic groups but the machinery that determines the fate of Rab species in the cytosol has not been elucidated in detail. In this study, we find that BAG6 (BAT3/Scythe) predominantly recognizes a cryptic portion of GDP-associated Rab8a, while its major GTP-bound active form is not recognized. The hydrophobic residues of the Switch I region of Rab8a are essential for its interaction with BAG6 and the degradation of GDP-Rab8a via the ubiquitin-proteasome system. BAG6 prevents the excess accumulation of inactive Rab8a, whose accumulation impairs intracellular membrane trafficking. BAG6 binds not only Rab8a but also a functionally distinct set of Rab family proteins, and is also required for the correct distribution of Golgi and endosomal markers. From these observations, we suggest that Rab proteins represent a novel set of substrates for BAG6, and the BAG6-mediated pathway is associated with the regulation of membrane vesicle trafficking events in mammalian cells., (© 2019 The Authors. Published under the terms of the CC BY 4.0 license.)

We treated a 70-year-old patient with Kommerell's diverticulum associated with an aberrant left subclavian artery and right aortic arch using single-stage total arch replacement with a commercially available open stent graft through only a median sternotomy. A four-branched prosthetic graft was implanted after insertion of the open stent graft through the anastomotic site under moderate hypothermia and cardiopulmonary bypass with selective cerebral perfusion. The aberrant subclavian artery was occluded by coil embolization from the distal site and anatomically reconstructed from the prosthetic graft. This approach is safe and effective and allows avoidance of a right thoracotomy and second stage intervention.

Background: Cardiac surgery for myelodysplastic syndrome (MDS) patients is challenging because anemia and neutropenia develop as a result of the syndrome, leading to infection and bleeding tendency during surgery. We report the case of minimally invasive mitral valve repair via a right mini-thoracotomy and perioperative use of granulocyte colony-stimulating factor (G-CSF) in a patient with MDS., Case Presentation: A 77-year-old man with myelodysplastic syndrome (MDS) was referred for surgical treatment for mitral valve regurgitation and underwent a minimally invasive mitral valve repair via a right mini-thoracotomy (MICS mitral procedure). On admission, laboratory results showed a leukocyte count of 1500/μL and neutrophils at 190/μL. Prior to surgery, a subcutaneous injection of granulocyte colony-stimulating factor (G-CSF) was given, based on a diagnosis of MDS by a hematologist. The MICS-mitral procedure using artificial chordae and an annular ring prosthesis was completed without requiring re-exploration for bleeding. Postoperatively, a G-CSF injection was administered and transfusion was required. There was no infection complication and the postoperative course was uneventful., Conclusion: A MICS-mitral procedure may be an effective option for MR patients with MDS who require a mitral valve repair to avoid postoperative infection and reduce the incidence of perioperative transfusion.

A 42-year-old woman with a large congenital giant arteriovenous malformation in the left supraclavicular fossa underwent surgical resection. Although endovascular treatment was initially planned, it was impossible to occlude the multiple feeding arteries (transverse cervical, clavicular branch of left internal mammary, thoracoacromial, anterior/posterior circumflex humeral), and the anatomy was difficult. After removal of the left clavicle, the arteriovenous malformation was exposed. Care was taken to not injure the brachial plexus, and each feeding artery was ligated, followed by division of the drainage veins. The postoperative course was uneventful, and no sign of recurrence has been seen.

Purpose: Postoperative atrial fibrillation (POAF) is a very common and important complication occurring after open heart surgery. Risk factors and prevention measure including β blocker use have been reported mainly in regard to patients who underwent coronary artery bypass grafting, while little is known about POAF following thoracic aortic surgery. In the present study, we examined risk factors related to POAF and effective prevention of POAF in patients who underwent thoracic aortic surgery., Patients and Methods: We evaluated 95 consecutive patients who underwent thoracic aortic surgery since 2010. We analyzed the relationship between perioperative factors and occurrence of POAF in the study cohort, as well as in 62 patients who had perioperative intravenous β blocker (landiolol) administration., Results: Following surgery, 21 (22%) of the patients had new onset POAF. The occurrence of POAF was related to that of stroke. Univariate analysis showed that age was a risk factor for POAF. In patients with landiolol, risk factors for POAF were age, arch aneurysm, and timing of landiolol administration. Six patients developed POAF during landiolol administration. However, of 56 patients who had not have POAF during landiolol administration, 8 developed POAF after stopping landiolol., Conclusion: Our findings show that the risk factor of POAF after thoracic aortic surgery is age, while perioperative administration of landiolol may reduce POAF incidence.

Background: Surgical treatment for endocarditis patients with a perivalvular abscess is still challenging., Methods and results: From 2009 to 2016, 470 patients underwent surgery for active endocarditis at 11 hospitals. Of these, 226 patients underwent aortic valve surgery. We compared the clinical results of 162 patients without a perivalvular abscess, 37 patients who required patch reconstruction of the aortic annulus (PR group) and 27 who underwent aortic root replacement (ARR group). Patients with a perivalvular abscess had a greater number ofStaphylococcusspecies and prosthetic valve endocarditis, a greater level of inflammation at diagnosis and symptomatic heart failure before surgery, especially in the ARR group. Nevertheless, the duration between diagnosis and surgery was similar, because of a high prevalence of intracranial hemorrhage in the ARR group. Hospital death occurred in 13 (9%) patients without a perivalvular abscess, in 4 (12%) in the PR and in 7 (32%) in the ARR group. Postoperative inflammation and end-organ function were similar between the groups. Overall survival of patients without a perivalvular abscess and that of the PR group was similar, but was significantly worse in the ARR group (P=0.050, 0.026). Freedom from endocarditis recurrence was similar among all patients., Conclusions: Patients treated with patch reconstruction showed favorable clinical results. Early surgical intervention is necessary when a refractory invasive infection is suspected.

Purpose: The perioperative management of chronic kidney disease (CKD) patients undergoing open-heart surgery is challenging. In this study, we evaluated the effects of tolvaptan in CKD patients after open-heart surgery., Methods: Between 2010 to 2015, 731 patients underwent open-heart surgery in our hospital. We consecutively selected 71 patients with stage IIIa-IV CKD and divided them into two groups. Those who received tolvaptan postoperatively were defined as the "Tolvaptan group" (n = 25) and those who did not were defined as the "Non-tolvaptan group" (n = 46). We compared the urine volume of postoperative days (POD) 1 and 2, the number of days to return to preoperative body weight (BW), and the change in the postoperative estimated glomerular filtration rate (eGFR)., Results: In the tolvaptan group, the urine volume was significantly larger (P = .04) and the duration to preoperative BW tended to be shorter. Overall, the postoperative change in the eGFR tended to be better in the tolvaptan group (P = .008). In particular, we found a significantly better trend in CKD stage IV (P = .04) patients and in the patients, whose cardiopulmonary bypass (CPB) time was longer than 120 min (P = .03)., Conclusions: Tolvaptan can safely be used for CKD patients undergoing open-heart surgery and can provide a feasible urine volume without leading to a deterioration of their renal function.

Objectives: Despite recent advances in perioperative management, postoperative atrial fibrillation/flutter (POAF) remains the most common complication after cardiac surgery. Therefore, it is important to determine related risk factors to establish effective management. However, most studies have focused on patients undergoing coronary artery bypass grafting and little is known about POAF in those who receive aortic valve replacement (AVR). We investigated the relationship of clinical predictors with POAF in patients undergoing AVR., Methods: A total of 119 patients who underwent AVR were enrolled in this study, and the relationships between POAF incidence and perioperative (preoperative, operative, postoperative) factors were examined., Results: POAF occurred in 47 patients (40%). In univariate analysis, older age was significantly associated with POAF occurrence, which was significantly related to prolonged intensive care unit (ICU) stay and postoperative stroke. It also showed patients with preoperative β-blocker experienced POAF less frequently than those without β-blocker. Multivariate analysis showed that preoperative β-blocker usage was an independent predictor of POAF. In patients who received both preoperative oral and postoperative intravenous β-blocker administrations, the incidence of POAF was reduced to 14% (3/22)., Conclusions: POAF frequently occurred in patients undergoing AVR, and was significantly related to prolonged ICU stay and postoperative stroke. Our findings show that advanced age and absence of preoperative β-blocker usage are risk factors for POAF. Furthermore, in patients undergoing AVR, perioperative intravenous β-blocker administration may be useful for prevention.

Objective: To identify the predictive factors for responders to tolvaptan, a novel vasopressin type 2 receptor antagonist for fluid management after cardiovascular surgery., Methods: Between January 2013 and May 2014, 113 patients were treated with tolvaptan for fluid management after cardiovascular surgery. As indicators for the effects of tolvaptan, change in bodyweight during the tolvaptan administration period and correlations with perioperative factors were assessed. Thirty-one patients were administered tolvaptan at the first day after surgery (early tolvaptan group). In this group, urine volume during the 6 h before the initial tolvaptan administration was compared with that at 6 h after administration., Results: For all the patients, the change in bodyweight during the tolvaptan administration period significantly correlated with pre-operative serum creatinine (r = 0.19, p = 0.04) and albumin levels before tolvaptan administration (r = -0.29, p = 0.002). In the early tolvaptan group, the ratio of urine volume at 6 h before and 6 h after the initial tolvaptan administration significantly correlated with the pre-operative serum creatinine level (r = 0.43, p = 0.02), the serum albumin level before tolvaptan administration (r = -0.50, p = 0.004), and change in bodyweight (r = 0.38, p = 0.03)., Conclusions: In patients undergoing cardiovascular surgery, deteriorating renal function, increased bodyweight, and hypoalbuminemia were found to be predictive factors for responders to tolvaptan for postoperative fluid management., Competing Interests: Hiroyuki Nishi has a potential conflict of interest with Otsuka Pharmaceutical, which consists of lecture fees and travel expenses. All the other authors have no conflict of interest.

Purpose: Lamotrigine (LTG) is used to treat epilepsy. The variability of LTG pharmacokinetics among individuals may be attributed to polymorphisms in the genes of uridine diphosphate glucuronosyltransferases (UGTs) 1A4 and UGT2B7 and/or combination with other drugs. In this study, we evaluated the association between LTG concentrations and patient characteristics such as genetic polymorphisms and the co-administration of antiepileptic drugs., Methods: We recruited 122 patients with epilepsy. LTG concentrations were measured in blood samples from each patient under steady-state condition. We assessed the influence of multiple factors on LTG concentrations and derived a formula for predicting LTG concentrations using multiple linear regression analysis., Results: We derived a formula to predict LTG concentrations that considers the daily dose of LTG, body weight, valproic acid concentration, phenytoin co-administration, and the co-administration of phenobarbital and/or carbamazepine as well as UGT1A4 142T>G and UGT2B7 -161C>T polymorphisms (adjusted coefficients of determination R (2) = 0.734). Furthermore, we used this formula to reveal a strong positive correlation between measured and predicted LTG concentrations (r (2) = 0.76, p < 0.001)., Conclusion: We derived a formula that will be useful in clinical practice for predicting LTG concentrations in patients with epilepsy.

BAG6 (also called Scythe) interacts with the exposed hydrophobic regions of newly synthesized proteins and escorts them to the degradation machinery through mechanisms that remain to be elucidated. In this study, we provide evidence that BAG6 physically interacts with the model defective protein substrate CL1 in a manner that depends directly on its short hydrophobicity. We found that the N terminus of BAG6 contains an evolutionarily conserved island tentatively designated the BAG6 ubiquitin-linked domain. Partial deletion of this domain in the BAG6 N-terminal fragment abolished in cell recognition of polyubiquitinated polypeptides as well as the hydrophobicity-mediated recognition of the CL1 degron in cell and in vitro. These observations suggest a mechanism whereby the BAG6 ubiquitin-linked domain provides a platform for discriminating substrates with shorter hydrophobicity stretches as a signal for defective proteins., (© 2015 FEBS.)

Background: Sac behavior after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) is considered as a surrogate for the risk of late rupture. The purpose of the study is to assess the sac behavior of AAAs after EVAR., Methods and Results: Late sac enlargement (LSE) (≥5 mm) and late sac shrinkage (LSS) (≥5 mm) were analyzed in 589 consecutive patients who were registered at 14 national centers in Japan. The proportions of patients who had LSE at 1, 3 and 5 years were 2.6% ± 0.7%, 10.0% ± 1.6% and 19.0% ± 2.9%. The proportions of patients who had LSS at 1, 3 and 5 years were 50.1% ± 0.7%, 59.2% ± 2.3% and 61.7% ± 2.7%. Multiple logistic regression analysis identified two variables as a risk factor for LSE; persistent endoleak (Odds ratio 9.56 (4.84-19.49), P <0.001) and low platelet count (Odds ratio 0.92 (0.86-0.99), P = 0.0224). The leading cause of endoleak in patients with LSE was type II., Conclusions: The incidence of LSE is not negligible over 5 year period. Patients with persistent endoleak and/or low platelet count should carefully be observed for LSE., Clinical Trial Registration: UMIN-CTR (UMIN000008345).

Purpose: Valproic acid (VPA), which is widely used to treat epilepsy, migraine, and bipolar disorder, can causes severe hyperammonemia. However, the mechanism responsible for this adverse effect is not readily apparent. We previously reported that phenytoin coadministration is a strong risk factor for the development of hyperammonemia during VPA-based therapy. In this study, we focused on glutamine synthetase, which catalyzes the synthesis of glutamine from glutamate and ammonia and examined the association with the development of hyperammonemia during VPA-based therapy., Methods: For this study, we recruited 202 Japanese pediatric patients having epilepsy. We selected three polymorphisms (rs10911070, rs10797771, and rs10911021) in the glutamine synthetase (GLUL) gene. Hyperammonemia was defined as a plasma ammonia level exceeding 200 or 170 μg/dL. We evaluated the association between the development of hyperammonemia during VPA-based therapy and the patient characteristics, including three GLUL polymorphisms., Results: The number of patients who developed hyperammonemia during VPA-based therapy was 20 (9.9%) using the 200 μg/dL cutoff value and 30 (14.9%) using the 170 μg/dL cutoff value. Using a multivariate logistic regression analysis, the GLUL rs10797771 polymorphism and phenytoin coadministration in the 200 μg/dL cutoff value, and female in addition to two factors in the 170 μg/dL cutoff value, had significant associations with a plasma ammonia level elevation during VPA-based therapy., Conclusion: Phenytoin coadministration, GLUL rs10797771 polymorphism in the 200μg/dL cutoff value, and female in addition to two factors in the 170μg/dL cutoff value, are independent risk factors for elevated plasma ammonia levels during VPA-based therapy., (Copyright © 2015 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Objectives: Left atrial (LA) dimension can predict atrial fibrillation (AF) recurrence after catheter-based or surgical ablation. Pulmonary vein isolation (PVI) may be a surgical option during aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG), though consensus regarding patient selection and late outcome is lacking., Methods: We studied 160 patients (mean age 70 ± 9 years) with paroxysmal AF who underwent radiofrequency-based PVI during AVR and/or CABG, and were followed up postoperatively for at least 6 months. Mean preoperative LA dimension was 44 ± 7 mm. Serial echocardiography was performed to evaluate left ventricular (LV) and LA dimensions, E/e', estimated systolic pulmonary artery (PA) pressure and degree of valvular regurgitation. Follow-up was completed with a mean duration of 47 ± 25 months., Results: At the latest follow-up, 133 patients (83%) remained in sinus rhythm. Preoperative LA dimension was independently associated with increased risk of AF recurrence at 6 months after surgery [adjusted odds ratio 1.3 per 1-mm increase in LA dimension, 95% confidence interval (CI) 1.1-1.6, P < 0.001]. Receiver-operating characteristic curve analysis demonstrated an optimal cut-off value for preoperative LA dimension of 45 mm to predict sinus rhythm restoration (98% for <45 mm vs 55% for ≥45 mm, P < 0.001). Patients with LA dimension ≥45 mm had a significantly lower 5-year survival rate (62 ± 7 vs 82 ± 7%, P = 0.025) and freedom from adverse events defined as cerebral infarction/haemorrhage, admission for heart failure, catheter ablation and permanent pacemaker implantation (58 ± 7 vs 91 ± 4%, P < 0.001). Multivariate analysis showed that preoperative LA dimension ≥45 mm was independently associated with adverse events (adjusted hazards ratio 2.4, 95% CI 1.2-5.1, P = 0.019). Serial echocardiography demonstrated improvement in LV systolic function irrespective of LA dimension, whereas patients with LA dimension ≥45 mm showed less improvement in LA dimension and systolic PA pressure (interaction effect P < 0.001) and persistent higher E/e' (group effect P < 0.001), along with aggravated tricuspid regurgitation., Conclusions: In patients with paroxysmal AF related to aortic valve disease and/or coronary artery disease, a dilated left atrium (≥45 mm) was associated with inferior AF- and event-free survival after PVI, accompanied by persistent abnormalities in cardiac and haemodynamic function. These findings may assist patient selection for PVI during AVR and/or CABG., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Unlabelled: Whether endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is a relative contraindication in patients with preoperative renal dysfunction (Pre-RD), remains controversial because the contrast medium may induce nephrotoxicity. In this study 1658 patients were treated at ten Japanese medical centers between January 2005 and March 2011 (Open surgery (OS) vs. EVAR: n = 1270 vs. n = 388). They were retrospectively analyzed. Multiple logistic regression analysis (MLRA) with pre- and intra-operative variables was applied to all patients. The endpoints induced onset of new dialysis and postoperative renal dysfunction (Post-RD), were defined as a 50% decrease or more from the preoperative estimated glomerular filtration rate (eGFR) level., Results: Early mortality, Post-RD, incidence of new dialysis in all patients were 1.6% (OS: EVAR = 1.9%:0.8%), 6% (OS: EVAR = 8%:2.3%) and 1.4% (OS: EVAR = 1.5%:1.0%) respectively. MLRA identified operation time, clamp of renal artery as risk factors for Post-RD, and operation time and Pre-eGFR level as risk factors for new dialysis., Conclusion: Although Post-RD was more frequently observed in the OS group, MLRA showed that the choice of OS or EVAR was not a risk factor for Post-RD and new dialysis. It was strongly suggested that using contrast medium during EVAR is not a contraindication to AAA repair in patients with Pre-RD. (This article is a translation of J Jpn Coll Angiol 2014; 54: 13-18.).

Valproic acid, which is widely used to treat various types of epilepsy, may cause severe hyperammonemia. However, the mechanism responsible for this side effect is not readily apparent. Polymorphisms in the genes encoding carbamoyl-phosphate synthase 1 (CPS1) and N-acetylglutamate synthase (NAGS) were recently reported to be risk factors for the development of hyperammonemia during valproic acid-based therapy. This study aimed to examine the influence of patient characteristics, including polymorphisms in CPS1 4217C>A and NAGS -3064C>A, on the development of hyperammonemia in Japanese pediatric epilepsy patients. The study included 177 pediatric epilepsy patients. The presence of a 4217C>A polymorphism in CPS1 was determined using an allele-specific polymerase chain reaction (PCR)-based method, and the presence of a -3064C>A polymorphism in NAGS was determined using a PCR-based restriction fragment length polymorphism method. Hyperammonemia was defined as a plasma ammonia level exceeding 200 μg/dL. We observed a significant difference between the combination of valproic acid with phenytoin and the development of hyperammonemia in both univariate and multivariate analyses. With regard to the CPS1 4217C>A polymorphism, we did not observe a significant association with the development of hyperammonemia. In conclusion, CPS1 4217C>A polymorphism may not be associated with the development of hyperammonemia in Japanese population., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Valproic acid (VPA) is widely used to treat various types of epilepsy. Interindividual variability in VPA pharmacokinetics may arise from genetic polymorphisms of VPA-metabolizing enzymes. This study aimed to examine the relationships between plasma VPA concentrations and the -161C>T single nucleotide polymorphism in uridine diphosphate glucuronosyltransferase (UGT) 2B7 genes in pediatric epilepsy patients., Methods: This study included 78 pediatric epilepsy patients carrying the cytochrome P450 (CYP) 2C9*1/*1 genotype and who were not treated with the enzyme inducers (phenytoin, phenobarbital, and carbamazepine), lamotrigine, and/or topiramate. CYP2C9*3 and UGT2B7 -161C>T polymorphisms were identified using methods based on polymerase chain reaction-restriction fragment length polymorphism. Blood samples were drawn from each patient under steady-state conditions, and plasma VPA concentrations were measured., Results: Significant differences in adjusted plasma VPA concentrations were observed between carriers of CC, CT, and TT genotypes in the UGT2B7 -161C>T polymorphism (P = 0.039). Patients with the CC genotype had lower adjusted plasma VPA concentrations than those with CT or TT genotype (P = 0.028)., Conclusions: These data suggest that the UGT2B7 -161C>T polymorphism in pediatric epilepsy patients carrying the CYP2C9*1/*1 genotype affects VPA concentration.

Background: The objective of the present study was to assess the hypothesis that the introduction of endovascular aneurysm repair (EVAR) into Japan has expanded the indication of abdominal aortic aneurysm (AAA) repair without increasing surgical mortality., Methods and Results: From 10 national hospitals, we registered a total of 2,154 consecutive patients (Open surgery [OS]: n=1,577, EVAR: n=577) over 8 years, divided into 4 time periods: Group I (2005-2006: n=522), Group II (2007-2008: n=475), Group III (2009-2010: n=551), Group IV, (2011-2012: n=606). Mean age increased over the 4 time periods (P<0.0001). The incidences of COPD, smoking history, history of abdominal surgery and concomitant malignancy significantly increased as well, while the numbers of patients with preoperative shock or high ASA status reduced over time. The proportion of EVAR in AAA repair increased from: 0% in Group I, 11.6% in Group II, 41.0% in Group III, to 48.8% in Group IV (P<0.0001). Early mortality was 0.8% in the EVAR and 3.4% in the OS (P<0.001) groups. Survival rates among the 4 groups free of all-cause death and aneurysm-related death at 1 year were 92.1-96.3% (P=0.1555) and 95.5-96.8% (P=0.9891), respectively. Multiple logistic regression analysis for surgical death failed to demonstrate survival advantage of EVAR over OS., Conclusions: Introduction of EVAR expanded the indication of AAA repair without increasing mortality, while high risk for anesthesia and emergency cases reduced over time. UMIN-CTR (UMIN000008345).

Objective: Total arch replacement, with a long elephant trunk (ET) anastomosed at the base of the innominate artery using an undersized graft, is performed for a variety of arch aneurysms. We investigated the long-term clinical outcomes of this procedure, as well as its long-term effectiveness for preventing retrograde flow into the aneurysm and further dilation of the descending aorta., Methods: We treated 127 consecutive patients with an arch aneurysm, who were divided into two groups according to the diameter of the descending aorta at the Th6-Th8 thoracic vertebral level: 35 mm or less (Single-ET, n = 94) and >35 mm (Staged-ET, n = 33). The graft diameter was undersized by 10-20% of the distal aortic diameter. ET length was determined by preoperative computed tomography (CT) to locate the distal end at Th6-Th8. Thrombosis around the ET and the descending aorta diameter around the distal end of the ET were evaluated using CT., Results: Two patients (1.6%) died within 30 days, while seven (5.5%) died in the hospital, three (2.4%) had a new stroke, three (2.4%) had permanent paraplegia and one (0.8%) had paraparesis. CT demonstrated complete thrombosis of the perigraft space around the ET in 81 patients (86%) in the Single-ET group and 11 (33%) in the Staged-ET group within 1 month after surgery, but not in the remaining 35 patients. Twenty-seven of the 35 patients without complete thrombosis underwent a subsequent second-stage operation. In those, the descending aorta showed no further dilation around the distal end of the ET, while new-onset perigraft perfusion occurred in two patients in the Single-ET group at 14 and 126 months, respectively. Overall survival was 89, 86, 78 and 74% at 1, 3, 5 and 7 years, respectively., Conclusions: Our operative strategy for extensive thoracic aortic aneurysms using a long ET technique yielded satisfactory short- and long-term outcomes.

Standard full median sternotomy for total arch replacement in tracheostomy patients may lead to mediastinitis and graft infection. Several approaches for typical cardiac surgery, including a T-shaped sternotomy, have been used in patients with both terminal and transient tracheostomas; however, these procedures offer inadequate surgical exposure of the arch vessels. We herein report the case of a 67-year-old man with a subacute type A aortic dissection with a terminal tracheostoma after total laryngectomy, who successfully underwent total arch replacement by a fourth intercostal thoracotomy performed using an anterior bilateral approach and the arch-first technique. To our knowledge, this is the first report of a case of total arch replacement in a patient with subacute aortic dissection and a terminal tracheostoma.

We report a rare case of a 58-year-old male with accidental occlusion of left main trunk (LMT) artery by injured aortic valve during percutaneous coronary intervention (PCI). Although we successfully bailed out this complication by urgent LMT stenting, aortic regurgitation developed immediately after PCI. Echocardiography detected a filamentous structure attached to the aortic valve. An elective aortic valve replacement surgery revealed that his right coronary cusp was torn into two filamentous strips. One strip accidentally plunged into LMT and was fixed by the intracoronary stent. Another strip floated in the aortic root and appeared as though vegetation attached to the aortic valve in case of acute infective endocarditis. Guiding catheters probably injured the aortic valve during PCI. This report reminded us of the importance of meticulous manipulation of a guiding catheter.

Objective: Early outcomes of open abdominal repair (OS) versus endovascular repair (EVAR) for abdominal aortic aneurysm were retrospectively analyzed, after commercialized devices for EVAR had become available in Japan., Patients and Methods: A total of 781 consecutive patients (OS, n = 522; EVAR, n = 259) were treated at ten medical centers between January 2008 and September 2010. The OS group comprised patients with preoperative shock (SOS, n = 34) and without shock (NOS, n = 488)., Results: Patients in the EVAR group were 3 years older than those in the NOS group. There was greater prevalence of hostile abdomen, on dialysis, chronic obstructive pulmonary disease on inhaled drug, and cerebrovascular disease in the EVAR group than in the NOS group. Surgical mortality was 16 cases (2.0% in all patients, EVAR: 0.8%, NOS: 1.4%, SOS: 21%). Hospital stay >30 days was documented in 52 (11%) with NOS, 11 (33%) with SOS, and 8 (3%) with EVAR. Thirty late deaths included 6 aneurysm related death and 14 cardiovascular causes at a mean follow up of 1.0 year. The survival rates freedom from all cause death at one year, were 95 ± 1% in NOS and 94 ± 2% in EVAR respectively., Conclusion: Though significant differences in patient characteristics among three groups were noted, early results were satisfactory.

Cardiac myxoma is the most common primary cardiac tumour, but infected cardiac myxoma is relatively rare. Infected cardiac myxoma is very fragile, and has a potential to lead to catastrophic disorder with systemic bacteremia, systemic mycotic embolism, and disseminated intravascular coagulation (DIC).We present here the successful surgical treatment of a case of infected left atrial myxoma with septic shock, DIC and cerebral infarction without hemorrahage. Collective review of 58 reported cases with infected cardiac myxoma revealed that surgical treatment for it were still challenging and its result was poor. Until date, only one successful surgical treatment for a case complicated by DIC and cerebral infarctions has been reported, and our report describes second such case of successful resection. Even though this report is limited to a case, only aggressive and prompt surgical intervention could relieve the intractable conditions in such a patient with extremely high risk.

Patients and Methods: In order to assess the early outcomes of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) in the Japanese population, a total of 183 patients who had EVAR at eight medical centers of the National Hospital Organization were retrospectively reviewed and registered. The mean number of registered cases in each center was 23 ± 17 (4-50 cases). Patient characteristics were male sex, 84%; mean age, 77 years; age ≥ 80 years, 40%., Results: In-hospital mortality was one case (0.5%). Endoleaks were observed at the end of the procedure in 35 patients (19%: type I: n = 4, II: n = 22, III, n = 3, IV: n = 6). Early morbidity included delayed wound healing or infection (n = 7), deterioration of renal dysfunction (n = 3), stroke (n = 2), postoperative bleeding (n = 2), gastrointestinal complications (n = 2), and peripheral thromboembolism (n = 2). Eleven late deaths included one of unknown cause and six cardiovascular causes at a mean follow up of 1.0 year. Survival rates of freedom from all causes of death and from aneurysm-related death at one year were 95.4% ± 1.7% and 99.5% ± 0.5%, respectively., Interpretation: Although registered patients carry a variety of risks, early outcomes were satisfactory. EVAR is an acceptable alternative treatment modality for treating AAA.

A 75-year-old man developed persistent dysphagia 2 months after successful total arch replacement with a long elephant trunk (ET) for a distal arch aneurysm. Enhanced computed tomography revealed not only complete thrombosis of the distal arch aneurysm, but also rapid expansion of another downstream aortic aneurysm with esophageal compression. Thoracic endovascular aortic repair was undertaken for this symptomatic aortic aneurysm, which was totally thrombo-excluded. ET might produce turbulent or jet-like blood flow from its tip in some situations and have a potential to accelerate the expansion of the downstream aneurysm. Additional endovascular ET completion is simple, effective, and less invasive.

Background: We studied the long-term outcome of arch aneurysm repair with a long elephant trunk (LET) anastomosed at the base of brachiocephalic artery., Methods: Between 1998 and 2008, 111 patients underwent arch aneurysm repair with LET. A 4-branched graft was sutured to the sinotubular junction, the distal ascending aorta transected, and a LET inserted into the aortic arch while selective cerebral perfusion was maintained. The graft distal end was anastomosed to the LET, incorporating the distal ascending aorta, and arch vessels were anastomosed to graft branches., Results: Concomitantly, 33 patients (30%) underwent other cardiac procedures, including 11 aortic root replacements. Two patients died (1.8%) within 30 days and 7 died (6.3%) after 30 days. Perioperative morbidity included 2 (1.8%) with stroke, 3 (2.7%) with paraplegia, and 1 (0.9%) with paraparesis. Postoperative computed tomography scans revealed complete aneurysmal thrombosis around the LET in 88 patients (79%), who were monitored without a second-stage procedure. Among 23 patients with incomplete thrombosis, 19 underwent a second-stage procedure to complete distal fixation of the LET. Overall survival was 88%, 83%, and 75%, at 1, 3, and 5 years after aneurysm repair with the LET. No aneurysm rupture or reexpansion occurred in patients with complete thrombosis. Four patients with incomplete thrombosis died of rupture before the second-stage procedure., Conclusions: Our results demonstrated safety and good durability of the LET technique and suggest that this technique is a simple and safe procedure that is applicable to a variety of arch aneurysms.

Objective: Chronic congestive liver dysfunction in advanced valvular disease remains an important co-morbidity in open heart surgery. The objective of this study was to explore the prognostic value in patients with severe valvular disease associated with congestive liver dysfunction., Methods: From 1997 to 2004, a total of 63 patients who had valvular disease with moderate or severe tricuspid regurgitation were studied. In addition to the indocyanine green retention rate at 15 min (ICG15) and the Child-Pugh score, we measured serum total bilirubin (T-bil), asparate aminotransferase (AST), alanine aminotransferase (ALT), cholinesterase (ChE), albumin (Alb) concentration, and prothrombin time. We compared these preoperative factors with postoperative liver dysfunction and mortality and attempted to develop a new liver function score., Results: There were eight in-hospital deaths (13%). Seventeen patients had postoperative liver dysfunction. The univariate analysis indicated there were significant differences in preoperative T-bil, Alb, ChE, ICG15, and Child-Pugh score between the patients with and without liver dysfunction. Multivariate logistic regression analysis also identified preoperative T-bil as a significant indicator of postoperative liver dysfunction and preoperative ChE as a predictor of mortality. Based on these findings, we introduced a liver function score to predict postoperative dysfunction and death., Conclusion: In addition to preoperative ChE, T-bil and Alb appeared to be valuable for producing obtainable prognostic information regarding postoperative liver dysfunction in patients with severe valvular disease. A new liver score, including T-bil, ChE, and Alb, is proposed for predicting postoperative hepatic dysfunction and outcome.

Purpose: The purpose of this study was to describe our current technique for aortic arch replacement using a four-branched arch graft and a long elephant trunk., Description: Using our method, the ascending aorta is replaced with a four-branched Hemashield arch graft (Hemashield Platinum, Woven Double Velour [Boston Scientific Corp, Wayne, NJ]) while cooling the patient. When 25 degrees C is reached, selective cerebral perfusion is started and the elephant trunk is inserted under open distal conditions into the descending aorta using a catching catheter introduced through a femoral artery. A distal aortic anastomosis is then performed between the four-branched graft and distal aorta incorporating the elephant trunk at the base of the innominate artery. Arch vessels are reconstructed separately during rewarming., Evaluation: Between October 1998 and December 2005, we performed the present technique in 52 patients with no operative deaths within 30 days after the procedure. The mean duration of hypothermic circulatory arrest was 24 +/- 5 minutes, whereas that of selective cerebral perfusion was 86 +/- 9 minutes., Conclusions: The technique described herein requires a shorter circulatory arrest time and is uniformly applicable to patients with extensive thoracic aortic aneurysms.

Background: We examined the relationships of left ventricular (LV) contractile state with LV geometry and hypertrophy in patients with aortic valve disease, and investigated the reversibility of LV hypertrophy and contractility following aortic valve replacement., Methods: Preoperative data from quantitative cineangiography and pressure measurements in 132 patients with chronic aortic valve disease, of whom 82 aortic regurgitation (AR), 41 aortic stenosis (AS), and 9 had mixed stenosis and regurgitation (AS-AR), were reviewed. Late after surgery, 59 of the patients (39 with AR, 20 with AS) were studied to elucidate the postoperative reversibility of LV performance and regression of LV hypertrophy., Results: Preoperatively, multiple comparison tests found significant changes in the variables of LV volumes and dimensions in relation to LV contractile state. In stepwise regression analysis, the LV mass index was initially incorporated into a multivariate regression model as an important correlate of LV contractile state. LV geometric variables showed either no or a poor correlation with contractile state. Following aortic valve replacement, improvement of LV contractile dysfunction and regression of LV hypertrophy were limited in many of the patients who had severe preoperative hypertrophy (LV mass index 200% of normal or greater). Further, a close association between LV hypertrophy and LV contractility persisted postoperatively., Conclusion: Our results suggest that the development of LV hypertrophy in terms of an increase in LV mass index, in contrast to changes in geometric patterns, is significantly associated with deterioration in contractile function. LV hypertrophy may become irreversible and pathological at equivalent degrees of hypertrophy (LV mass index >/=200% of normal), regardless of the type of aortic valve lesion.

A 68-year-old man presenting with abdominal distention was found on enhanced computed tomography to have a dilated ascending aorta and aortic dissection (DeBakey IIIb). Through a median sternotomy, we performed a total arch replacement using a four-branched Hemashield graft (Meadox Medical, Oakland, NJ) and a long elephant trunk anastomosis at the base of the innominate artery. Postoperatively, a pseudolumen of the descending aorta was effectively thrombo-excluded to the T12 level. Visceral blood flow was preserved, and the patient's postoperative course was uneventful.

We present herein a simple and uniform repair technique for combined aortic arch and root aneurysms. Our method is performed under an open distal procedure and includes selective antegrade cerebral perfusion, adequate myocardial preservation, a four-branched composite valve graft, and a long elephant trunk anastomosis proximal to the innominate artery. The technique was designed to reduce morbidity and mortality associated with aortic arch and root replacements, as well as allow for easier performance of subsequent downstream operations.

We report a rare case of invasive type AB thymoma (WHO classification system) with intracaval and intracardiac extension into the right atrium. A cardiopulmonary bypass facilitated an en bloc excision of the tumor with a lobectomy, along with a combined resection of the right atrium and reconstruction of the bilateral brachiocephalic veins and right atrium. Aggressive surgical intervention should be considered in such cases, as long-term prognosis is primarily dependent on a complete resection of the extended thymoma.

Background: Severe valvular heart disease is often complicated by congestive liver dysfunction, which greatly compromises the operative results. We evaluated congestive liver dysfunction by a novel approach using technetium-99 m galactosyl human serum albumin ((99m)Tc-GSA) with liver scintigraphy., Methods: Between 1998 and 2004, we performed scintigraphy accompanied by (99m)Tc-GSA in 28 patients who had valvular heart disease with moderate-to-severe tricuspid regurgitation and who showed symptoms of right heart failure. Based on the results, we calculated a receptor index (LHL15) and an index of blood clearance (HH15) and assessed the correlation between these factors and postoperative liver dysfunction, defined as the maximum serum total bilirubin level (max T-bil) as >2.0 mg/dl., Results: Nineteen patients, including four who died in hospital, had postoperative liver dysfunction. The level of HH15 was significantly higher and the level of cholinesterase was significantly lower (P < 0.05) in patients with liver dysfunction than in those without liver dysfunction. Multivariate logistic regression analysis identified HH15 as the most sensitive indicator of postoperative hepatic dysfunction., Conclusions: The level of HH15 calculated using scintigraphy with (99m)Tc-GSA is a clinically useful predictor of postoperative liver dysfunction in patients with severe valvular disease.

The involvement of oral bacteria in the pathogenesis of cardiovascular diseases has been the focus of attention in many studies, and several periodontal pathogens have been detected in diseased cardiovascular lesions, suggesting relationships between oral microorganisms and cardiovascular diseases. However, no information is available regarding the involvement of cariogenic pathogens such as Streptococcus mutans. The presence of oral streptococcal species and periodontitis-related bacteria in 35 heart valve and 27 atheromatous plaque clinical specimens, as well as 32 dental plaque specimens from the same subjects, was analyzed using a PCR method. Furthermore, broad-range PCR with DNA sequencing analysis was employed to identify the bacterial species in those samples. Streptococcus mutans was frequently detected in the heart valve (69%) and atheromatous plaque (74%) specimens, while other bacterial species, including those related to periodontitis, were detected with much lower frequencies. The bacterial composition in cardiovascular tissues was found to be markedly distinct from that in dental plaque, with only a limited number of species, including S. mutans, in the cardiovascular regions shown to have possibly originated from the oral cavity. Semiquantitative assay results revealed that S. mutans was detected in significant quantities in the heart valve (40%) and atheromatous plaque (48%) specimens, whereas the quantities of all other tested bacterial species, including several related to periodontitis, were negligible in the cardiovascular samples. These results indicate that S. mutans is a possible causative agent of cardiovascular disease.

Streptococcus mutans, known to be an aetiologic agent of dental caries, also causes infective endocarditis (IE), although a comparison of isolates from the oral cavity and infected heart valve of the same patient has not been reported. In the present study, infected heart valve and dental plaque samples from a patient with IE were analysed. Broad-range PCR with DNA sequencing revealed that 50 clones from the dental plaque isolates were composed of oral streptococci and periodontopathic bacteria, whereas only Streptococcus mutans was detected in 50 clones from the heart valve. Eighteen strains of Streptococcus mutans were isolated from dental plaque and seven from the heart valve, and the biochemical properties of each were in accordance with those of Streptococcus mutans. DNA fingerprinting analysis revealed that all the oral isolates of Streptococcus mutans had similar patterns, which were different from those of the isolates from the infected heart valve. Western blotting using glucosyltransferase (GTF)-specific antiserum showed that the seven strains from the heart valve lacked the three types of intact GTF. In addition, the sucrose-dependent adhesion rates of these isolates were significantly lower than those of the oral isolates (P<0.001). Furthermore, the isolates from the heart valve were less susceptible to erythromycin and kanamycin. These results indicate that the properties of the Streptococcus mutans strains isolated from the infected valve were different from those of typical oral strains, which may be related to the effects of IE.

We describe a simple reproducible method for chordal replacement using expanded polytetrafluoroethylene sutures during a mitral valve repair. With this technique, fine length adjustments of the new chordae are easy to make and it is possible to tie the two ends of the suture securely without slippage.

We report a case of pulmonary artery (PA) dissection complicating lung transplantation. A 30-year-old man with primary pulmonary hypertension underwent bilateral single lung transplantation. Thirty hours postoperatively he had signs of obstruction of the right main pulmonary artery develop due to dissection demonstrated on transesophageal echocardiography and pulmonary arteriography. Surgical repair of the dissection with reanastomosis of the pulmonary artery was successfully carried out, and the patient subsequently improved to a favorable condition. Pulmonary hypertension is a risk factor of pulmonary artery dissection; our case suggested that underlying chronic pulmonary hypertension might have led to this rare and life-threatening anastomotic problem after lung transplantation.

Background: Previously, perfusion defect in the left ventricle was detected by thallium-201 (201T1) single-photon emission computed tomography (SPECT) in aortic regurgitation (AR). The significance of 201T1 SPECT, however, has not been clarified. Limited information is available regarding the relationship between functional characteristics and scintigraphic findings., Hypothesis: The purpose of this study was to elucidate the role of exercise 201T1 SPECT in assessing myocardial perfusion or structural change in chronic AR. We examined the correlation between 201T1 scintigraphic findings and left ventricular (LV) function parameters in 11 patients., Methods: Defect volume ratio (DVR) in exercise 201T1 SPECT was used as a parameter of the range of abnormal thallium distribution. Left ventricular parameters were obtained by right and retrograde left cardiac catheterizations. The relationship between DVR and the parameters was analyzed., Results: The DVR ranged from 1.0 to 28.3% (average 12.1 + 8.5 %). There was a significant correlation (r = 0.77, p < 0.05) between DVR and end-diastolic volume index (EDVI), a definite correlation (r = 0.66, p < 0.01) between DVR and end-systolic volume index (ESVI), and a good correlation (r = -0.77, p <0.05) between DVR and end-systolic wall stress (ESS)/ ESVI; however, no such correlation was found between DVR and ejection fraction., Conclusion: All patients showed abnormal defects in 201T1 accumulation scattered across the entire ventricle. A strong correlation between DVR and ESS/ESVI, an index of myocardial contractility, was a major finding of this study, suggesting a significant association between abnormal myocardial perfusion or structural alteration and reduction in myocardial contractility in chronic AR.