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Poststernotomy pain (PSP), a primary concern after sternotomy, can negatively affect patients' satisfaction with surgery and quality of life. Many clinical trials have been conducted to examine the usefulness of lidocaine patches (LPs) for postoperative pain control for multiple types of surgery; however, the results of these trials are inconsistent. In addition, little is known about the use of LPs after cardiac procedures that require sternotomy. This prospective, double-blind, placebo-controlled trial aimed to determine the efficacy of the 5% LP application at the sternotomy site for reducing PSP and rescue opioid consumption.The patients were randomly assigned to receive either the 5% LP or the placebo patch on each side of the incision site immediately after the surgery. The intensity of pain at 6, 12, 24, and 48 h after the patch application; the total dose of rescue opioids; incidence of nausea, vomiting, and sleep disturbance; and use of antiemetics were compared between the 2 groups.Fifty-seven (31 in the LP group and 26 in the placebo group) patients were included. The pain intensity was significantly lower in the LP group at each time point (66%-68% pain reduction, P 0.001, interaction of time × treatment P = 0.69). In addition, the total dose of rescue opioids used for 48 h was significantly lower in the L group (27.2% reduction, P = 0.008). No significant differences were found in other outcome variables between the 2 groups.The application of a 5% LP on each side of the sternotomy site can reduce PSP and additional opioid use without significant adverse effects in patients undergoing sternotomy. Thus, it can be considered as a standard and routine modality along with other analgesic medications for the management of PSP. Clinical Trial Registry in South Korea identifier: KCT0000476.

Background The association between oxidized low-density lipoprotein (OxLDL) and plaque instability in coronary and carotid artery disease is well established. However, the association between OxLDL and the histologic changes of plaque in peripheral artery disease has not been clearly elucidated. This study aims to investigate the association between plasma OxLDL and histologic plaque instability in patients with peripheral artery disease. Methods Prospectively obtained plaques from 48 patients who underwent endovascular atherectomy (n = 20), surgical endarterectomy (n = 9), or bypass surgery (n = 19) for treatment of atherosclerotic femoropopliteal artery disease were evaluated for histologic fibrosis, sclerosis, calcification, necrosis, cholesterol cleft, and foamy macrophages using hematoxylin and eosin, oil red O, and immunohistochemical staining. Unstable plaques were defined as plaques that were positive for foamy macrophages and with lipid content of more than 10% of the total plaque area. Plasma OxLDL levels were measured using an enzyme-linked immunosorbent assay (Mercodia AB, Uppsala, Sweden). Results Of the 48 patients, 26 (54%) had unstable plaques. The unstable plaque group was younger, had fewer angiographic total occlusions, less calcification, and more CD68-positive and LOX-1-positive cells than the stable plaque group. Plasma OxLDL levels were significantly higher in the unstable plaque group than in the stable plaque group (57.4 ± 13.9 vs. 47.2 ± 13.6 U/L, P = 0.014). Multivariate analysis revealed that plasma OxLDL level, smoking, angiographic nontotal occlusion, and statin nonuse were independent predictors of unstable plaque. Conclusions Among patients with peripheral artery disease, the histologic instability of femoropopliteal plaque was independently associated with high plasma OxLDL, smoking, nontotal occlusion, and statin nonuse. Further large-scale studies are necessary to evaluate the role of noninvasive OxLDL measurement for predicting plaque instability and future adverse vascular event.

Background The aim of this study was to determine the associations between subclinical hypothyroidism (SCH) and long-term cardiovascular outcomes after coronary artery bypass grafting (CABG) or heart valve surgery (HVS). Methods We retrospectively reviewed and compared all-cause mortality, cardiovascular mortality, and cardiovascular events in 461 patients who underwent CABG and 104 patients who underwent HVS. Results During a mean±standard deviation follow-up duration of 7.6±3.8 years, there were 187 all-cause deaths, 97 cardiovascular deaths, 127 major adverse cardiovascular events (MACE), 11 myocardial infarctions, one unstable angina, 70 strokes, 30 hospitalizations due to heart failure, 101 atrial fibrillation, and 33 coronary revascularizations. The incidence of all-cause mortality after CABG was significantly higher in patients with SCH (n=36, 55.4%) than in euthyroid patients (n=120, 30.3%), with a hazard ratio of 1.70 (95% confidence interval, 1.10 to 2.63; P=0.018) after adjustment for age, sex, current smoking status, body mass index, underlying diseases, left ventricular dysfunction, and emergency operation. Interestingly, low total triiodothyronine (T3) levels in euthyroid patients who underwent CABG were significantly associated with increased risks of all-cause mortality, cardiovascular mortality, and MACE, but those associations were not observed in HVS patients. Both free thyroxine and thyroid-stimulating hormone levels in euthyroid patients were not related with any cardiovascular outcomes in either the CABG or HVS group. Conclusion SCH or low total T3 might be associated with a poor prognosis after CABG, but not after HVS, implying that preoperative thyroid hormonal status may be important in ischemic heart disease patients.

We have performed off-pump coronary artery bypass grafting and also performed early postoperative angiography to assess anastomosis accuracy and patency in most of our patients requiring surgical revascularization.Of 3083 patients who underwent isolated coronary artery bypass grafting between 1998 and 2017, 2919 patients (94.7%) underwent off-pump coronary artery bypass grafting. Conduits for distal anastomoses were left internal thoracic artery (n = 2764), right internal thoracic artery (n = 866), right gastroepiploic artery (n = 997), radial artery (n = 16), and saphenous vein (n = 1505). Since the introduction of transit-time flow measurement in 2000, we revised abnormal grafts intraoperatively. Early (≤7 days) angiography was performed in 2820 patients (96.6%) at 1.5 ± 1.2 postoperative days, and surgical intervention was performed based on angiographic findings.Operative mortality was 1.1% (32 of 2919). Average number of distal anastomoses was 3.2 ± 1.0. Intraoperative flowmetry-guided revision for distal anastomosis failures was performed in 109 of 8585 distal anastomoses (1.3%). Angiography showed an overall patency of 98.2% (8836 of 9001): 99.0% (5484 of 5540) for arterial and 96.9% (3352 of 3461) for venous conduits (P.001). Patency of venous conduits was 87.2% (231 of 265) for free grafts and 97.7% (3121 of 3196) for composite grafts (P = .001). After the introduction of transit-time flow measurement, patency of arterial conduits became significantly higher (97.2% vs 99.2%; P = .038); however, patency of free venous conduits was not significantly improved (86.0% vs 91.4%; P = .181). Early re-intervention according to angiographic findings was performed in 76 patients (2.7%). Reevaluation of graft patency before discharge in 31 who underwent revision of distal anastomoses showed improved patency (65.1% [56 of 86] vs 95.3% [82 of 86]; P.001).Intraoperative flowmetry and revision of abnormal grafts improved early arterial graft patency, and reoperation based on early angiographic findings may further improve graft patency at the time of discharge.

Background Some studies comparing minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) have reported MIDCAB's superiority, but they did not investigate contemporary PCI with newer generation drug-eluting stents (DES). We compared clinical outcomes after MIDCAB with previously reported outcomes after PCI with second-generation DES.Methods and Results:We retrospectively reviewed the records of patients treated with MIDCAB. Baseline characteristics and clinical outcomes after MIDCAB were compared with those for left anterior descending artery disease treated via PCI. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), a composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke, and target vessel revascularization (TVR). A propensity score-matching (PSM) analysis was conducted to adjust for between-group differences in baseline characteristics. We analyzed 77 patients treated with MIDCAB and 2,206 treated with PCI. The MIDCAB group was older and had more severe coronary disease and a higher incidence of left ventricular dysfunction. Over a 3-year follow-up, the PCI group had favorable MACCE outcomes. After PSM, there were no between-group differences in MACCE (MIDCAB, 15.6% vs. PCI, 23.4%; hazard ratio [HR], 0.80; 95% CI: 0.38-1.68, P=0.548) or TVR (MIDCAB, 2.6% vs. PCI, 5.2%; HR, 0.51; 95% CI: 0.10-3.09, P=0.509). Conclusions Clinical outcomes were similar between MIDCAB and PCI using second-generation DES over 3 years of follow-up.

Background We compared early and 2-year clinical outcomes of sutureless aortic valve replacement (SAVR) with conventional aortic valve replacement (CAVR) in a nationwide study based on claims data. Methods From December 2016 to November 2018, 3,173 patients underwent bioprosthetic aortic valve replacements. SAVR and CAVR were performed in 641 and 2,532 patients, respectively. Propensity score-matched analysis was performed in 640 patient pairs. Results Operative mortality rate was 2.8% without significant differences between the SAVR (3.4%) and CAVR (2.3%) groups (P = 0.324). There were no significant differences in postoperative morbidities between the groups except for permanent pacemaker (PPM) implantation. PPM implantation rate was significantly higher in the SAVR (3.8%) than in the CAVR group (0.9%) (P < 0.001). One- and two-year overall survival was 89.1% and 87.5%, respectively, without significant differences between the groups (SAVR group vs. CAVR group = 89.9% and 90.5% vs. 87.2% and 88.7%, respectively; P = 0.475). There were no significant differences in the cumulative incidence of cardiac death, stroke, aortic valve reoperation and infective endocarditis between the groups. Cumulative PPM implantation incidence at 6 months in the CAVR was 1.1%, and no patient required PPM implantation after 6 months. In the SAVR, the cumulative PPM implantation incidence at 0.5, one, and two years was 3.9%, 5.0% and 5.6%, respectively. The cumulative PPM implantation rate was higher in the SAVR group than in the CAVR group (P < 0.001). Conclusion Early and 2-year clinical outcomes between SAVR and CAVR were not different except for a high rate of permanent pacemaker implantation in the SAVR group., Graphical Abstract

We aimed to investigate long-term cardiovascular sequelae after coronary artery bypass grafting (CABG) in patients with subclinical hypothyroidism (SCH). All-cause and cardiovascular-related mortality, and cardiovascular events were retrospectively reviewed in 222 euthyroid and 36 SCH patients who underwent CABG. During a mean follow-up period of 8.2 ± 4.1 years, there were 90 incidents of all-cause deaths, 20 cardiovascular-related deaths, 70 major cardiovascular adverse events, 6 myocardial infarctions, 12 unstable anginas, 31 strokes, 23 hospitalizations due to heart failure, 15 atrial fibrillation (AF) events, and 27 coronary revascularizations. The incidence rate of coronary revascularization was significantly higher in patients with SCH (n = 6, 16.6%) than in euthyroid patients (n = 20, 9.0%), with a hazard ratio (HR) of 3.179 (95% confidence interval [CI] 1.174, 8.605; p = 0.023) after adjustment. In subgroup analysis, SCH patients who experienced postoperative AF within 3 months after CABG surgery had a significantly higher risk of coronary revascularization (n = 4, 25.0%) than euthyroid patients without AF (n = 14, 8.9%) after adjustment (HR 11.759, 95% CI 2.747, 50.343, p = 0.001). The frequency of fatal or nonfatal unstable angina was also higher in patients with SCH (n = 2, 12.5%) than in euthyroid patients (n = 4, 2.5%) (HR 16.999, 95% CI 2.242, 128.860, p = 0.006). In conclusion, preoperative SCH is associated with less favorable cardiovascular outcomes, especially coronary revascularization after CABG. Moreover, SCH patients who develop postoperative AF exhibit significantly increased risks of unstable angina and coronary revascularization. Preoperative evaluation of thyroid function may be helpful for predicting long-term outcomes after CABG.

This study aimed to investigate the effectiveness of near-infrared spectroscopy (NIRS) monitoring for the early detection of limb ischemia in patients who were placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) via femoral artery. We prospectively used NIRS monitoring for the early detection of limb ischemia in 28 adult patients, who were supported with peripheral VA-ECMO between August 2013 and August 2014 (NIRS group). A decision to perform distal perfusion catheterization was made in accordance with the regional oxygen saturation (rSO2) values provided by the NIRS system. For the comparison of outcome, the medical records of 36 adult patients who had been previously supported with peripheral VA-ECMO without NIRS monitoring (Control group), between July 2012 and July 2013, were retrospectively reviewed. There was no significant difference between the frequency of distal perfusion in both groups (p = 0.435). The mean time to distal perfusion is shorter in the NIRS group (19.6 ± 21.4 vs. 42.0 ± 69.0 hours). No patient underwent fasciotomy in the NIRS group, while 13.9% did in the control group (p = 0.040). We think that NIRS monitoring is a useful and reliable method for the early detection of limb ischemia in patients undergoing peripheral VA-ECMO. Its application may allow timely correction of perfusion deficits and the prevention of compartment syndrome and limb complications.

BackgroundFibroblast growth factor 21 (FGF21) is a novel metabolic regulator that has beneficial effects on glucose and lipid metabolism. However, plasma FGF21 levels are paradoxically increased in type 2 diabetes mellitus (T2DM) and obesity, suggesting resistance to this ligand. FGF21 acts mainly on adipose tissue and ectopic fat accumulation is a typical feature in metabolic deterioration such as diabetes, metabolic syndrome, and cardiovascular disease.ObjectiveTo investigate the relationship between FGF21 resistance and ectopic fat accumulation.Research design and methodsSubjects who underwent 64-slice multidetector CT (MDCT) were enrolled (n=190). Plasma FGF21 levels and MDCT data of ectopic fats at various sites were analyzed. Human visceral and subcutaneous fat tissues from abdominal and coronary artery bypass surgery were obtained. FGF21 receptor expression and postreceptor signaling in different fat deposits of both control and T2DM subjects were analyzed.ResultsPlasma FGF21 levels were significantly associated with body mass index, triglyceride, homeostatic model assessment of insulin resistance, and Matsuda index. Plasma FGF21 levels were significantly higher in patients with T2DM than in the pre-diabetes and normal glucose tolerance groups. The ectopic fat phenotypes (visceral, epicardial, intrahepatic, and intramuscular fat) of T2DM were significantly higher than controls. Plasma FGF21 levels were elevated and exhibited a strong positive correlation with ectopic fat accumulation in T2DM. The expression of genes comprising the FGF21 signaling pathway was also lower in visceral fat than in subcutaneous fat in this disease.ConclusionsHuman FGF21 resistance in T2DM could result from increases in FGF21-resistant ectopic fat accumulation. Our study provides novel clinical evidence linking FGF21 resistance and T2DM pathogenesis.

Background Adults with unoperated congenitally corrected transposition of the great arteries are rare but form a distinct group among adults with congenital heart disease. Patients with congenitally corrected transposition of the great arteries often have one or more associated cardiac anomalies that dictate the need for, and timing of, surgical intervention in childhood. However, in a proportion of patients, the hemodynamics does not require surgical attention during childhood, and, in some patients, a correct diagnosis is not established until adulthood. Here we report an adult case of unoperated congenitally corrected transposition of the great arteries with a large ventricular septal defect and probable pulmonary arterial hypertension. Case presentation Our patient was a 46-year-old Korean man. Transthoracic echocardiography and cardiac catheterization demonstrated hemodynamically balanced ventricles with a non-regurgitant systemic atrioventricular valve, normal pulmonary arterial pressure, and a reasonable difference between the oxygen saturation values of the aorta and pulmonary trunk, even with the presence of a large ventricular septal defect. Further morphological assessments using cardiac computed tomography and three-dimensional modeling/printing of his heart revealed that the mitral valve was straddling over the posteriorly positioned ventricular septal defect, which could explain the functional and anatomical subvalvular pulmonary stenosis and a small amount of shunt flow through the large ventricular septal defect. We interpreted this combination of cardiac defects as able to sustain his stable cardiac function. Thus, we decided to maintain his unoperated status. Conclusion A detailed anatomical understanding based on transthoracic echocardiography, cardiac computed tomography, and three-dimensional printing can justify a decision to not operate in cases of congenitally corrected transposition of the great arteries with hemodynamically balanced pulmonary stenosis and a ventricular septal defect, as observed in the present case. Electronic supplementary material The online version of this article (10.1186/s13256-019-2145-1) contains supplementary material, which is available to authorized users.

This study aimed to examine the association between preadmission statin use and 90-day mortality in critically ill patients and to investigate whether this association differed according to statin type and dose. We hypothesized that preadmission statin use was associated with lower 90-day mortality.This retrospective cohort study analyzed the medical records of all adult patients admitted to the intensive care unit in a single tertiary academic hospital between January 2012 and December 2017. Data including preadmission statin use, statin subtype, and daily dosage were collected, and the associations between these variables and 90-day mortality after intensive care unit admission were examined. The primary endpoint was 90-day mortality.A total of 24,928 patients (7,396 statin users and 17,532 non-statin users) were included. After propensity score matching, 5,354 statin users and 7,758 non-statin users were finally included. The 90-day mortality rate was significantly higher in non-statin users (918 of 7,758; 11.8%) than in statin users (455 of 5,354; 8.5%; P0.001). In Cox regression analysis, the 90-day mortality rate was lower among statin users than among non-statin users (hazard ratio: 0.70, 95% CI: 0.63 to 0.79; P0.001). Rosuvastatin use was associated with 42% lower 90-day mortality (hazard ratio: 0.58, 95% CI: 0.47 to 0.72; P0.001). There were no specific significant differences in the association between daily statin dose and 90-day mortality. In competing risk analysis, the risk of noncardiovascular 90-day mortality in statin users was 32% lower than that in non-statin users (hazard ratio: 0.68, 95% CI: 0.60 to 0.78; P0.001). Meanwhile, cardiovascular 90-day mortality was not significantly associated with statin use.Preadmission statin use was associated with a lower 90-day mortality. This association was more evident in the rosuvastatin group and with noncardiovascular 90-day mortality; no differences were seen according to daily dosage intensity.

This study aims to evaluate the association between target vessel size and graft patency in the right IMA–right coronary territory anastomosis. A total of 402 patients who underwent CABG between 2005 and 2016 using the right IMA Y-graft to the posterolateral branch or posterior descending artery were enrolled. Preoperative coronary angiography was utilized to measure the size of the target coronary arteries in the right territory. Follow-up angiography and computed tomography at 6 to 12 months were used to determine graft patency. Thirty patients (7.5%) were found to have occluded graft. Larger target vessel size was associated with lower risk of graft occlusion (OR: 0.18, 95% CI:0.05–0.62, P = .007). The receiver operating characteristic (ROC) curve showed that the cutoff-value of 1.93 mm was found to have the maximum sum of sensitivity and specificity for graft patency (Area under the curve (AUC): 0.65, P = .01). Excluding patients with right coronary artery total occlusion, the discriminative performance of target vessel size became more prominent (AUC: 0.76, P

The cholecystokinin (CCK) receptor is known as a receptor that is overexpressed in many human tumors. The present study was designed to investigate the targeting ability of cyclic CCK analogue in AR42J pancreatic cells. The CCK analogues, DOTA-K(glucose)-Gly-Trp-Nle-Asp-Phe (DOTA-glucose-CCK) and DOTA-Nle-cyclo(Glu-Trp-Nle-Asp-Phe-Lys-NH2) (DOTA-[Nle]-cCCK), were synthesized and radiolabeled with Lu-177, and competitive binding was evaluated. The binding appearance of synthesized peptide with AR42J cells was evaluated by confocal microscopy. And bio-distribution was performed in AR42J xenografted mice. Synthesized peptides were prepared by a solid phase synthesis method, and their purity was over 98%. DOTA is the chelating agent for Lu-177-labeling, in which the peptides were radiolabeled with Lu-177 by a high radiolabeling yield. A competitive displacement of I-125-CCK8 on the AR42J cells revealed that the 50% inhibitory concentration value (IC50) was 12.3 nM of DOTA-glucose-CCK and 1.7 nM of DOTA-[Nle]-cCCK. Radio-labeled peptides were accumulated in AR42J tumor in vivo, and % ID/g of the tumor was 0.4 and 0.9 at 2 h p.i. It was concluded that Lu-177-DOTA-[Nle]-cCCK has higher binding affinity than Lu-177-DOTA-glucose-CCK and can be a potential candidate as a targeting modality for a CCK receptor over-expressing tumors. (C) 2016 The Authors. Production and hosting by Elsevier B.V. on behalf of Japanese Pharmacological Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The aim of this study was to investigate the association of chronic opioid usage with 90-day mortality in critically ill patients after admission to the ICU.This retrospective cohort study analysed the medical records of adult patients admitted to ICUs in a tertiary academic hospital between January 2012 and December 2017. Patients taking opioids regularly for more than 4 weeks before ICU admission were defined as chronic opioid users, whereas the others were defined as opioid-naïve patients.We selected 18 409 patients for this study, including 757 (4.1%) chronic opioid users. After propensity matching, 2990 patients (chronic opioid users, 757; opioid-naïve, patient: 2233) were included in the analysis. The odds of 90-day mortality were higher in chronic opioid users than in opioid-naïve patients using both the generalised estimating equation model for the propensity-matched cohort (odds ratio=1.90; 95% confidence interval, 1.57-2.31; P0.001) and the multivariable logistic regression model for the entire cohort (odds ratio=2.20; 95% confidence interval, 1.81-2.66; P0.001). Additionally, this association was significant in cancer patients and non-chronic kidney disease (CKD) patients and was not significant in non-cancer and CKD patients.Our results suggest that in a cohort of critically ill adult patients, chronic opioid use is associated with an increase in 90-day mortality. This association was more evident in cancer patients and non-CKD patients.

Perioperative positive fluid balance has negative effects on short-term outcomes, such as surgical complications, although the associations with postoperative mortality remain unclear. This study evaluated the associations of perioperative fluid balance (FB) with 30-day mortality and acute kidney injury (AKI) after postoperative intensive care unit (ICU) admission. This retrospective study evaluated data from adult patients who were admitted to the ICU after surgery during 2012–2016. Weight-based cumulative FB (%) was calculated for 3 time periods [postoperative day (POD) 0 (24 h), 0–1 (48 h), and 0–2 (72 h)] and was categorized as positive (≥ 5%), mild to moderate positive (5–10%), severe positive (> 10%), normal (0–5%), or negative (

Decay-accelerating factor (CD55 or DAF) inhibits complement-dependent cytotoxicity. We determined that CD55 is overexpressed in 76.47% of human non-small cell lung cancer tissue specimens. We therefore developed a lutetium-177-labeled chimeric monoclonal antibody against CD55. CD55-specific single-chain variable fragment (scFv) was selected from a naïve chicken scFv phage-display library, converted to IgG, and radiolabeled with lutetium-177 to generate a 177Lu-anti-CD55 antibody. We then charaterized the biodistribution of this antibody in a mouse model of pleural metastatic lung cancer. The 177Lu-anti-CD55 antibody was primarily retained in tumor tissue rather than normal tissue. Treatment of the mice with 177Lu-anti-CD55 reduced the growth of lung tumors and improved median survival in vivo by two-fold compared to controls. Finally, 177Lu-anti-CD55 also enhanced the antitumor activity of cisplatin both in vitro and in vivo. These data suggest 177Lu-anti-CD55 antibody is a promising theranostic agent for pleural metastatic lung cancer.

The gastrin-releasing peptide receptor (GRPR) has been shown to be overexpressed in many human tumors, including prostate, colon, gastric, breast, pancreatic, and small cell lung cancers. Because bombesin (BBS) binds to GRPR with high affinity, BBS derivatives have been labeled with various radionuclides and have been demonstrated to be successful candidates for peptide receptor radiotherapy (PRRT). The present study describes the in vitro and in vivo preclinical characteristics of (177)Lu-DOTA-Lys(glucose)-4 aminobenzoic acid-BBS7-14 ((177)Lu-DOTA-gluBBN) to prepare radiolabeled candidates for the treatment of GRPR-expressing prostate tumors.(177)Lu-DOTA-gluBBN was prepared as previously published [1]. Human prostate PC-3 tumor cells were used to determine the binding (Kd) retention and efflux of (177)Lu-DOTA-gluBBN. Pharmacokinetic, imaging, and radiotherapy studies were performed in PC-3 xenografted mice.The Kd value of (177)Lu-DOTA-gluBBN was 0.63 nM, with a maximum binding capacity (Bmax) of 669.7 fmol/10(6) cells (4.04×10(5) GRPR/cell). During a 2-hr incubation, 90.1±0.4% of the cell-associated radio-peptide was internalized, and 56.3±7.1% of the internalized radio-peptide was externalized in vitro. High amounts of the radio-peptide were rapidly accumulated in a PC-3 tumor in vivo, and the % ID/g of the tumor was 12.42±2.15 1 hr p.i. The radio-peptide was quickly cleared from the blood, yielding tumor-to-blood ratios of 39.22±17.36 at 1 hr p.i. and 330.67±131.23 at 24hr p.i. In addition, (177)Lu-DOTA-gluBBN was clearly visualized in PC-3 tumors 1 hr p.i. and significantly inhibited the tumor growth (P0.05). Treatment-related toxicity in the pancreas and kidneys was not observed, except for slight glomerulopathy.The pharmacokinetic, imaging, and therapy studies suggest that this (177)Lu-DOTA-gluBBN has promising characteristics for application in nuclear medicine, namely, for the diagnosis and treatment of GRPR-overexpressing prostate tumors.

Bombesin binds with selectivity and high affinity to a Gastrin-releasing peptide receptor (GRPR), which is highly overexpressed in prostate cancer cells. The present study describes the in vitro and in vivo biological characteristics of DOTA-Ala(SO3H)-Aminooctanoyl-Gln-Trp-Ala-Val-N methyl Gly-His-Statine-Leu-NH2 (DOTA-sBBNA), an antagonist analogue of bombesin peptide for the targeting of GRPR. DOTA-sBBNA was synthesized and labeled with (177)Lu as previously published. A saturation assay on PC-3 human prostate cancer cells revealed that the Kd value of the radiolabeled peptide was 1.88 nM with a maximum binding capacity (Bmax) of 289.3 fmol/10(6) cells. The radio-peptide slowly internalized, and 24.4±0.5% of the total binding was internalized in 4hr. Biodistribution studies were conducted in healthy and PC-3 xenografted balb/c mice, which showed high uptake and retention of tumor-associated radioactivity in PC-3 xenografted mice. The tumor-to-blood ratio was 126.02±9.36 at 1.5hr p.i., and was increased to 216.33±61.58 at 24hr p.i., which means that the radiolabeled peptide was highly accumulated in a tumor and rapidly cleared from the blood pool. The GRPR is also over-expressed in Korean prostate cancer patients. These results suggest that this (177)Lu-labeled peptide has promising characteristics for application in nuclear medicine, namely for the diagnosis and treatment of GRPR over-expressing prostate tumors.

OBJECTIVES Reimplantation of branch vessels is an important component of thoraco-abdominal aortic aneurysm repair. The goal of this study was to assess the anatomical results of branch vessel reimplantation, which have rarely been investigated. METHODS Among 168 patients who underwent computed tomography after thoraco-abdominal aortic aneurysm repair, the technique of branch vessel reimplantation and determination of their patency were investigated. Late computed tomographic images were available for 81 patients (mean interval 55.7 ± 29.4 months); they were examined for long-term changes. RESULTS The early patency rate of the coeliac trunk (n = 150), superior mesenteric artery (n = 126) and right renal artery (n = 109) was 100%, regardless of the reimplantation technique. For 101 left renal arteries reimplanted end-to-end to the branch grafts, the early patency rate was 94.1%. Late new occlusion was found in 1 of 44 (2.3%) of the right renal arteries and in 1 of 53 (1.9%) of the left renal arteries reimplanted into the branch grafts. The patency rate of 240 segmental (intercostal or lumbar) arteries reimplanted in 116 patients differed based on the reimplantation technique used: 92.1% for a large multiple-branch patch, 83.0% for a single-branch patch and 31.0% for graft interposition. Spinal cord ischaemia was significantly more frequent in patients who had occlusion of reimplanted segmental arteries than in the remaining patients: 18.2% vs 4.4% (P = 0.022). Late computed tomography revealed ≥5 mm dilatation in 2 of 41 visceral branch patches (4.9%) and in 9 of 55 segmental artery patches (16.4%). CONCLUSIONS Visceral branches reimplanted during thoraco-abdominal aortic aneurysm repair showed excellent patency. In contrast, segmental artery reimplantation by graft interposition showed a high rate of occlusion that was associated with a higher incidence of spinal cord ischaemia.

Context A previous genome-wide association study showed that a genetic variant of sortilin was associated with the risk of coronary artery disease (CAD). However, the role of circulating sortilin is still unknown. We investigated the potential role of plasma sortilin as a biomarker for CAD and diabetes mellitus. Methods We enrolled statin-naïve subjects with CAD (n = 31) who underwent coronary artery bypass surgery and control subjects (n = 116) who were free from CAD as evaluated by coronary CT angiography. The presence of diabetes mellitus was evaluated and plasma sortilin levels were measured with a commercial ELISA kit. Results Plasma sortilin levels were higher in subjects with CAD and subjects with diabetes mellitus than in those without CAD or diabetes mellitus. Subjects in the highest sortilin tertile group were older and had higher glucose and HbA1c levels, but lipid profiles in the three tertile groups were comparable. Multivariable logistic regression analysis revealed that sortilin levels were independently associated with CAD. In addition, the receiver operating characteristic curve analysis showed that plasma sortilin levels could identify the presence of CAD or diabetes mellitus. Conclusions Elevated circulating sortilin levels are associated with CAD and diabetes mellitus and can be used as a biomarker of both diseases in statin-naïve subjects.

Little is known about the clinical significance of intraluminal atheroma (ILA) in ascending and arch aneurysm (Asc-ArcA) regarding aneurysm expansion and associated cardiovascular events.We retrospectively investigated 70 consecutive patients with Asc-ArcA who underwent serial multidetector computed tomography between 2004 and 2011. We evaluated the diameter of the aneurysm, as well as the presence and characteristics of ILA. We also evaluated the characteristics of atheroma in terms of the presence of high-risk plaque (4 mm in plaque thickness), vulnerable plaque (60 HU in density), ulcerated plaque (extension of the contrast medium beyond the vascular lumen into the surrounding plaque with3 mm orifice), and complex plaque (having all three characteristics). The annual expansion rate of Asc-ArcA and factors associated with cardiovascular events were evaluated.During a median of 47 months of follow-up, cryptogenic stroke occurred in 13 patients (18.6%). Univariate and multivariate logistic regression analyses revealed the presence of ILA as an independent predictor for cryptogenic stroke. Cryptogenic stroke occurred in all 5 patients with complex atheroma. The annual expansion rate of Asc-ArcA was not significantly associated with the occurrence of cryptogenic stroke.In patients with low to intermediate risk sized Asc-ArcA, ILA, especially complex atheroma, is strongly associated with cryptogenic stroke. Thus, the presence and characteristics of ILA within Asc-ArcA should be carefully evaluated for the prevention of adverse events.

ObjectiveNeuroprotective effects of the peroxisome proliferator-activated receptor gamma (PPARγ) agonist in cerebral ischemia have been reported, but the effect of a PPARγ agonist on spinal cord ischemia has not been investigated. The objective of this study was to investigate the effect of a PPARγ agonist on spinal cord ischemia. Pioglitazone, a PPARγ agonist, was administered in a rat model of spinal cord ischemia, and the extent of neurological damage and histological alterations were assessed.MethodsForty-five rats were randomly enrolled into one of the three groups: (1) pioglitazone group (group PIO): rats were treated with pioglitazone 24 hours before ischemia; (2) control group (group C): rats were treated with the same volume of saline 24 hours before ischemia; and (3) sham group (group sham): rats were treated with the same volume of saline 24 hours before the sham surgery. Spinal cord ischemia was induced using a balloon-tipped catheter placed on the proximal descending aorta. Neurologic function was assessed using the motor deficit index (0 = normal, 6 = complete paralysis) during the 48 hours after reperfusion. Histological and biochemical evaluations were then performed.ResultsCompared with group C, group PIO presented with lower motor deficit index 48 hours after reperfusion (5.0 [4.0-6.0] vs 3.0 [2.0-3.0]; group C vs group PIO, respectively; P < .001). Group PIO presented with a higher number of normal motor neurons (10.7 [8.1-11.9] vs 14.7 [14.0-15.3]; group C vs group PIO, respectively; P = .009) and a smaller area of infarcts (48.4% [46.3%-54.0%] vs 16.8% [11.5%-18.3%]; group C vs group PIO, respectively; P = .009) when compared with group C. The degree of inflammatory reactions, assessed by microglia activities, was significantly reduced in group PIO. Oxidative stress level, assessed using malonydialdehyde assay, was significantly reduced in group PIO relative to group C (192.21% [173.5%-206.4%] of sham vs 141.1% [131.7%-152.1%] of sham; group C vs group PIO, respectively; P = .007). The sham group exhibited no abnormality upon neurological or histological examination.ConclusionsPPARγ agonist pioglitazone pretreatment significantly reduces infarct volume and attenuates neurological deficits following spinal cord ischemia. The possible mechanism of neuroprotection by PPARγ agonist may involve modulation of inflammatory reaction and oxidative stress.Clinical RelevanceSpinal cord ischemia is a major issue in thoracoabdominal aortic surgery. The proliferator-activated receptor agonists have been reported to exert protective effects on ischemia in various organs including cerebral ischemia. This study investigated the effect of a proliferator-activated receptor gamma agonist pioglitazone on spinal cord ischemia in a rat model of spinal cord ischemia. Our results present a protective effect of pioglitazone pretreatment to attenuate spinal cord ischemic injury. Considering that pioglitazone is currently a U.S. Food and Drug Administration-approved agent for treatment of type 2 diabetes, it may be applied in clinical practice to attenuate spinal cord ischemia injury following thoracoabdominal aortic surgery.

OBJECTIVE This study aimed to investigate the efficiency and safety of resternotomy performed in the intensive care unit (ICU) for emergent bleeding control after cardiac surgery when transport of the patient to the operating room (OR) was unsafe or delayed. METHODS Medical records were retrospectively reviewed for 101 patients who underwent resternotomy for bleeding control after cardiac surgery between July 2003 and July 2013. A reoperation was performed in the OR for 61 patients (the OR group) and in the ICU for 40 patients (the ICU group). Perioperative features and outcomes were compared between the two groups. RESULTS The ICU group had a higher incidence of cardiopulmonary resuscitation before resternotomy (27.5% vs 3.3%, p

Background: Coronary endarterectomy (CE) may be a good option for complete revascularization of diffuse coronary artery diseases, but it has not been widely used because the outcomes have not been definitively identified. This study aims to evaluate the mid-term clinical results of CE and compare the outcomes according to the use of cardiopulmonary bypass (CPB) and the surgical technique used. Methods: Between 2004 and 2014, 69 cases of CE were performed in 64 patients. We divided the pa­tients into two groups: 1) on-pump coronary artery bypass with coronary endarterectomy (ONCAB-CE) versus off-pump coronary artery bypass with coronary endarterectomy (OPCAB-CE), and 2) “open” versus “closed” surgical techniques. Operative mortality and major morbidity, were investigated includ­ing perioperative myocardial infarction (PMI), and overall survival. Results: Operative mortality was 4.7% (3/64), and no PMI was observed in the study. No statistical differences in operative mortality rate between the ONCAB-CE and OPCAB-CE groups were found (3.1% vs. 6.2%, p = 1.0) or between open versus closed techniques (6.7% vs. 2.9%, p = 0.6). The incidence of major morbidity including cerebrovascular accident, atrial fibrillation, acute renal failure, mediastinitis, respiratory complications, and bleeding was comparable between all groups. There were seven late mortalities, and no differences were found in overall survival rate between all groups. Conclusions: Coronary endarterectomy appears to be a safe option for patients with diffuse coronary artery disease, regardless of whether CPB or a specified selection of surgical techniques are used.

The potential cardioprotective effects of the novel vaccine peptide GV1001 were evaluated in myocardial ischemia‑reperfusion injury induced rat models. GV1001 is a human telomerase reverse transcriptase derived peptide, which has been reported to possess both anti‑tumor and anti‑inflammatory effects. The normal saline (control group) and various concentrations (0.001‑10 mg/kg) of GV1001 were administered directly to the right ventricle anterior wall before induction of ischemia. The was induced by Tightening the snare around the left anterior descending coronary artery for 40 min, before releasing the snare for 10 min induced the myocardial ischemia‑reperfusion injury and was conducted in Sprague‑Dawley rats. The area at risk, histology, apoptotic cells, neutrophils and inflammatory cytokines were analyzed from the excised heart tissue following myocardial ischemia‑reperfusion injury. The area at risk was protected by concentrations of GV1001 equal to or higher than 0.01 mg/kg. At 0.1 mg/kg and higher concentrations of GV1001, the hemorrhage in the heart was attenuated, while severe congestion was reported in the control group. Apoptotic cells, myeloperoxidase activity and inflammatory cytokines [tumor necrosis factor (TNF)‑α and interleukin (IL)‑6] revealed decreased levels in a dose‑dependent manner with respect to GV1001 concentration. The group treated with 10 mg/kg GV1001 demonstrated 59.73% apoptotic cells (P

The value of late gadolinium-enhanced (LGE) magnetic resonance imaging (MRI) for the prediction of functional recovery after surgical revascularization has been previously established. However, the impact of LGE-MRI on the long-term prognosis after coronary artery bypass grafting (CABG) remains incompletely understood. Therefore, we aimed to evaluate the long-term prognostic value of LGE-MRI, based on the presence or absence of left ventricular (LV) dysfunction, in patients with coronary artery disease undergoing CABG. One hundred forty-six consecutive patients underwent cine- and LGE-MRI before CABG. Adverse cardiac events included cardiac death, nonfatal myocardial infarction, heart failure, and unstable angina. A 3-year landmark analysis of the primary end point was also performed for patients surviving beyond 3 years after CABG. During a median follow-up of 9.4 years, 44 patients (30%) experienced adverse cardiac events. Although a LV ejection fraction50% was associated only with adverse cardiac events at 3 years after CABG, LGE was associated with a worse outcome both at and beyond 3 years after CABG. In the overall study population, LGE presence (adjusted hazard ratio [HR] 2.58; p = 0.027), score (adjusted HR 1.06; p0.001), and extent (adjusted HR 1.08; p0.001) were independent predictors of adverse cardiac events. Moreover, in both the LV ejection fraction50% and ≥50% groups, the LGE extent was an independent predictor of adverse cardiac events. In conclusion, our qualitative and quantitative analyses of LGE-MRI provide long-term prognostic information after surgical revascularization. The LGE extent was a strong predictor of adverse cardiac events, independent of the LV function.

Preoperative radiological identification of the Adamkiewicz artery and intraoperative neurologic monitoring are known to be helpful for preventing paraplegia after thoracoabdominal aorta replacement. To answer whether they should be used routinely, we investigated the incidence of spinal cord ischemia after extensive descending aortic repair without using such modalities.We retrospectively reviewed the outcome of 95 patients who underwent extensive descending thoracic (DTA) or thoracoabdominal aorta (TAA) repair without the Adamkiewicz artery identification or neurologic monitoring from 2006 through 2010. Spinal cord protection strategy consisted of distal aortic perfusion, cerebrospinal fluid drainage, mild hypothermia, and maintenance of hypertension (systolic≥120mmHg) through the second postoperative day. A few segmental arteries were empirically selected for reimplantation based on the size and the amount of backbleeding; overall 1.4 per patient, 0.3 for DTA, 1.4 for type I, 2.4 for type II, 0.9 for type III, and 0 for type IV TAA.Two patients died early after surgery. All the remaining patients awoke without paraplegia or paraparesis. Delayed deficit occurred in 7 patients (7.4%) after hypotensive events caused by sedation, bleeding, respiratory distress, or cardiac dysfunction. Three patients (3.2%) became permanently paraplegic and the other four recovered completely within 48 hours after cerebrospinal fluid drainage and elevation of systemic blood pressure.Even without the Adamkiewicz artery identification and neuromonitoring, the incidence of immediate paraplegia could be kept low by applying the strategy based on the modern concept of cord perfusion. The relatively high incidence of delayed deficit suggests the importance of postoperative hemodynamic management and prevention of cardiopulmonary complications.

The purpose of this study was to determine what proportion of patients with an abdominal aortic aneurysm (AAA) would be eligible for endovascular aneurysm repair (EVAR) and to examine the major determinants for suitability of EVAR with the currently available indications. We retrospectively reviewed 3-D reconstructed computed tomography angiography of 88 patients with an atherosclerotic AAA who underwent open repair or EVAR between October 2003 and October 2010 at the Cardiovascular Center, Seoul National University Bundang Hospital. Of the 88 patients, 71 (80.7%) were treated with open repair and 17 (19.3%) were treated with EVAR. The rate of minor complications, postprocedural intensive care unit stay, and total hospital stay were significantly lower in the EVAR group. When the suitability of EVAR was reevaluated using morphologic criteria, a total of 33 (37.5%) patients were considered eligible for EVAR. Multivariate analysis revealed that proximal neck length, proximal neck angle, and aneurismal sac size were independent determinants for suitability of EVAR. Taking into account the increased clinical experience and the availability of new devices, EVAR would be applicable in about 40% of atherosclerotic AAA cases in this series of Korean patients. Accurate identification of candidates for EVAR by detailed preoperative evaluation, especially for morphologic characteristics, is essential.

The endocannabinoid system in animals and humans is involved in the onset of diverse diseases, including obesity and diabetic nephropathy, which is a major end-stage renal disease characterized by high glucose (HG)-induced apoptosis of mesangial cells. Endocannabinoids induce physiological and behavioral effects by activating two specific receptors, cannabinoid receptor 1 (CB1R) and cannabinoid receptor 2 (CB2R). However, the pathophysiology of CB1R in diabetic nephropathy has not been elucidated. We investigated the effects of HG on CB1R expression and its signaling pathways in primary cultured rat mesangial cells. HG significantly increased CB1R mRNA and protein levels in a time-dependent manner and induced CB1R internalization. NF-κB and cPLA2were involved in the HG-induced increase in CB1R levels. Using a CB1R antagonist (AM251) and CB1siRNA transfection, we showed that HG-induced CB1R is linked to apoptosis. Specifically, HG inhibited the expression of GRP78, but induced increases in endoplasmic reticulum (ER) stress proteins, including phosphorylated (p)-protein kinase-like ER-associated kinase, p-eukaryotic initiation factor 2α, p-activating transcription factor-4, and C/EBP homologous protein. In addition, HG increased the Bax/Bcl-2 ratio and increased the amounts of cleaved poly(ADP-ribose) polymerase and caspase-3. These apoptotic effects were prevented by AM251 and by the downregulation of CB1R expression by small interfering RNA. We propose a mechanism by which blockade of CB1R attenuates HG-induced apoptosis in rat mesangial cells. Our findings suggest that blockade of CB1R may be a potential therapy in diabetic nephropathy.

We aimed to evaluate image quality, radiation dose and diagnostic accuracy of coronary CT angiography (CCTA) with a prospectively gated transverse-axial scan (PGT) compared with a retrospectively gated helical scan (RGH), using a 64-slice scanner in patients who underwent coronary artery bypass graft (CABG). Of the 131 consecutive patients that underwent CABG using 64-slice multidetector row computed tomography during 2008, patients with heart rate (HR) of

Objective: In our institution, computerised tomographic (CT) angiography has been performed as a near-routine test before coronary artery bypass grafting (CABG) to evaluate the aorta and its branches. We aimed to determine its impact on operative procedure and perioperative management. Methods: From January 2006 through December 2008, neck-to-leg systemic arteries were evaluated by 64-slice multidetector CT scan in 284 patients before CABG. For them, medical records and cardiac surgery database were retrospectively reviewed to investigate the incidence of pathologic lesions of the aorta and its major branches, other incidental lesions and procedure- or management-related decision affectedbyCTangiography.Results:In 36 patients(12.7%),cannulation andclampingoftheascendingaortawerethoughttoo dangerous because of severe atherosclerotic change. The use of cardiopulmonary bypass was inevitable in 10 of them, and postoperative mortality rate was significantlyhigher(3/10,30%)thanintheremainingpatients(2/274,0.7%).Conduitselectionorgraftingstrategywaschangeddueto severeleft subclavian artery stenosis or leg vein varicosity in 18 patients (6.3%). For the following problems, surgical interventions were performed in 34 patients (12.0%) concomitantly or during the same admission with CABG; � 90% stenosis in carotid (5.6%), iliofemoral (11.6%) or renal (4.6%) arteries, aortic aneurysm (14.4%, six of them met surgical indication) and incidental malignant neoplasm (2.8%). Counting all of the above, preoperativeCTangiography affectedrisk assessment, CABGprocedure itself,perioperativemanagement or follow-upplan in 142patients(50%). Conclusions:Because preoperative CTangiographyconsiderably affectedmanagement in one half of patients, we recommendits use as a routine test before CABG, unless contraindicated. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

To evaluate the appropriateness of commercial guideline in selecting the size of balloon for intraaortic counterpulsation in Asian patients, we analyzed the relationship between aortic dimensions measured from computed tomography and body indexes. There were 125 patients who underwent the computed tomography. They were divided into three height groups [

Background Some studies have proposed that subclinical hypothyroidism (SCH) has adverse effects on the cardiovascular system, but little is known about the effect on patients undergoing cardiovascular operations. We examined the influence of preoperative SCH on postoperative outcome in patients undergoing coronary artery bypass grafting (CABG). Methods Among patients who underwent CABG between July 2005 and June 2007 at Seoul National University Bundang Hospital, 224 with normal thyroid function and 36 with SCH were enrolled. Preoperative risks and postoperative outcomes were evaluated prospectively without thyroid hormone replacement. Results There were no significant differences in primary outcomes (major adverse cardiovascular events) and secondary outcomes such as wound problems, mediastinitis, leg infection, respiratory complications, delirium, or reoperation during the same hospitalization. However, patients with SCH had a higher incidence of postoperative atrial fibrillation than those with normal thyroid function after adjustment for age, gender, body mass index, and other independent variables such as emergency operation, the use of cardiopulmonary bypass, combined valvular operation, preoperative creatinine levels, left ventricular systolic dysfunction, and nonuse of β-blockers (45.5% vs 29%; odds ratio, 2.552; 95% confidence interval, 1.117 to 5.830; p = 0.026). Conclusions SCH appears to influence the postoperative outcome for patients by increasing the development of postoperative atrial fibrillation. However, it is still unproven whether preoperative thyroxine replacement therapy for patients with SCH might prevent postoperative atrial fibrillation after CABG.

Background Persistent false lumen in the descending aorta after repair of acute type I dissection adversely affects long-term prognosis. In this study, we investigated changes of the descending aortic false lumen during the midterm postoperative period. Methods Postoperative computed tomographic (CT) images of 122 patients who underwent conventional ascending with or without arch replacement for acute type I dissection were reviewed. Patency and width of false lumen and maximal diameter of the aorta were compared between early and last follow-up images. Changes were analyzed separately in the thoracic and abdominal segments. Results In early CT, thoracic false lumen was patent in 85 patients (69.7%), and abdominal false lumen was patent in 111 patients (91.0%). Among these, the false lumen remained patent after a mean interval of 33.6 months in 69 patients (81.1%) and 105 patients (94.6%), respectively. In 58 patients (47.5%), the descending aorta dilated by 1 cm or more. Dilatation occurred more frequently in the thoracic aorta and in patients with patent or wide false lumens, larger aortic diameter, Marfan syndrome, younger age, and male sex. Meanwhile, shrinkage of thoracic false lumen occurred in 36 patients (29.5%). Such shrinkage occurred in 23 of 24 patients (95.8%) who had thrombosed and narrow false lumens in the thoracic aorta. Conclusions Early postoperative characteristics of false lumen were helpful for predicting both dilation and regression. Our data show not only a high incidence of descending aortic dilatation after repair of acute type I dissection, but also shrinkage of thoracic false lumen in some patients. These findings can be used as control data for determining the benefit of more extensive or new surgical approaches.

Background The purpose of this study was to determine causes and characteristics of early postoperative mortality focusing on postoperative day 1 (POD 1). Methods We reviewed the electronic medical records of patients who died within 7 days after surgery under anesthesia at a tertiary university hospital from January 2004 to December 2014. Postoperative mortalities were divided into POD 1 group and POD 7 group, which included death that occurred from days 2 to 7 after surgery. Characteristics of POD 1 group were compared with those of POD 7 group. Results The mortality rates of POD 1 and POD 7 groups were 3.6 and 7.8 per 10,000 anesthesia, respectively. The incidence of POD 1 mortality is higher than any other day of the week of surgery. The incidences of massive transfusion, intraoperative cardiac arrest, and intraoperative use of epinephrine were higher in POD 1 group than in POD 7 group. In adults, the proportion of emergency operations was higher in POD 1 group than in POD 7 group. The leading cause of death in POD 1 group was hypovolemic and cardiogenic shock, whereas that in POD 7 group was distributive shock. Human factor-related mortality was more frequent in POD 1 group (15.3%) compared with POD 7 group (6.1%). Conclusions The characteristics of POD 1 mortality were different from those of POD 2–7 mortality. A large proportion of early postoperative deaths were due to POD 1 mortality. Human factor-related causes were more associated with POD 1 mortality, indicating much room for improvement.

Background The complement component C1q triggers activation of the classical immune pathway and can bind to adiponectin (APN). Recently, some studies have been reported that serum C1q-APN/total APN ratio correlates with atherosclerosis and coronary artery disease (CAD). We assessed the relationships between C1q related variables and the severity of CAD, and investigated the localization of the C1q–APN complex. Methods The sample included 153 subjects comprising healthy controls and patients with subclinical or overt CAD. We measured the serum concentrations of C1q, total APN, and high-molecular weight (HMW)-APN, and the amount of C1q–APN complex. We identified the sites of C1q–APN complex deposition in various adipose tissues and blood vessels. Results Serum concentrations of C1q and HMW-APN and the C1q/HMW-APN ratio were independently associated with the severity of coronary stenosis. The amount of C1q–APN complex was significantly higher in patients with CAD compared with controls. C1q and APN co-localized in perivascular areas of subcutaneous, visceral, and pericardial fat tissues, and the internal mammary artery of patients with severe CAD. Conclusions Serum C1q concentration and the C1q/HMW-APN ratio were independent markers of coronary artery stenosis. The amount of C1q–APN complex was significantly greater in serum from CAD patients. C1q and APN co-localized to perivascular areas in adipose tissue and blood vessels. The association between the increased amount of the C1q–APN complex and CAD should be investigated further.

In this study, we evaluated the efficacy of the discharge Acute Physiology and Chronic Health Evaluation (APACHE) II score in predicting post-intensive care unit (ICU) mortality and ICU readmission during the same hospitalisation in a surgical ICU. Of 1190 patients who were admitted to the ICU and stayed >48 hours between October 2007 and March 2010, 23 (1.9%) died and 86 (7.2%) were readmitted after initial ICU discharge, with 26 (3.0%) admitted within 48 hours. The area under the receiver operating characteristics curve of the discharge and admission APACHE II scores in predicting in-hospital mortality was 0.631 (95% confidence interval [CI] 0.603 to 0.658) and 0.669 (95% CI 0.642 to 0.696), respectively ( P=0.510). The area under the receiver operating characteristics curve of discharge and admission APACHE II scores for predicting all forms of readmission was 0.606 (95% CI 0.578 to 0.634) and 0.574 (95% CI 0.545 to 0.602), respectively ( P=0.316). The area under the receiver operating characteristics curve of discharge APACHE II score in predicting early ICU readmissions was, however, higher than that of admission APACHE II score (0.688 [95% CI 0.660 to 0.714] versus 0.505 [95% CI 0.476 to 0.534], P=0.001). The discharge APACHE II score (odds ratio [OR] 1.1, 95% CI 1.01 to 1.22, P=0.024), unplanned ICU readmission (OR 20.0, 95% CI 7.6 to 53.1, P=0.001), eosinopenia at ICU discharge (OR 6.0, 95% CI 1.34 to 26.9, P=0.019), and hospital length-of-stay before ICU admission (OR 1.02, 95% CI 1.01 to 1.03, P=0.021) were significant independent factors in predicting post-ICU mortality. This study suggests that the discharge APACHE II score may be useful in predicting post-ICU mortality and is superior to the admission APACHE II score in predicting early ICU readmission in surgical ICU patients.

Objectives: Debate on the proper timing of pulmonary valve replacement (PVR) after repair of tetralogy of Fallot (TOF) is still continuing. Significant pulmonary regurgitation (PR) could result in right ventricular (RV) dysfunction, exercise intolerance, arrhythmia, and sudden death. We analyzed clinical results of PVR after repair of TOF to investigate potential risk factor for late outcomes. Methods: From January 1993 to July 2002, 58 patients (38 males and 20 females) received PVR after repair of TOF. More than moderate degree of PR was observed in these patients by echocardiography. Mean age at PVR was 13.5 ^ 9.6 years (1.2‐ 44) and TOF repair was performed at 5.2 ^ 7.1 years of age (0.5‐ 34). Therefore, PVR was performed at 8.3 ^ 5.2 years (4 months ‐ 28 years) after repair. Preoperative electrocardiogram showed complete right bundle branch block in 49 patients (84.5%). Mean duration of QRS complex was 142 ^ 30 ms. Major arrhythmia occurred in eight patients. Twenty-nine patients complained decreased physical activity and 10 patients showed clinical signs of right heart failure. Results: Early death occurred in one patient (2.5%). Major complication occurred in three patients (complete heart block in two, aortic rupture in one). Follow-up was performed for 2.5 ^ 2.4 years (46 days ‐ 10.3 years). There was no late death. Postoperative cardiothoracic ratio was significantly decreased (0.61 ^ 0.07 to 0.55 ^ 0.06, P , 0:001). Marked symptomatic improvement was noted in all patients. Postoperative symptomatic group ðn ¼ 14Þ showed older age at repair of TOF (12.5 ^ 10.7 vs 2.6 ^ 2.3 years, P ¼ 0:003), older age at PVR (23.2 ^ 12.8 vs 10.1 ^ 5.0 years, P ¼ 0:001), longer interval between repair of TOF and PVR (10.6 ^ 7.0 vs 7.5 ^ 4.2 years, P , 0:05), higher degree of functional class (2.4 ^ 0.5 vs 1.4 ^ 0.8, P , 0:001), and longer duration of hospitalization (30.0 ^ 14.2 vs 18.9 ^ 11.4 days, P ¼ 0:004) than postoperative asymptomatic group ðn ¼ 43Þ: Conclusions: In patients with significant PR after repair of TOF, PVR had clinical benefits including symptomatic improvement with low mortality and morbidity. Proper timing must be carefully selected according to objective evaluation of RV function. In our study, earlier PVR prior to symptomatic manifestation showed beneficial effects. q 2004 Elsevier B.V. All rights reserved.

We present successful procedures for 2 infants who had the Taussig-Bing anomaly with subaortic stenosis and coarctation of the aorta. The initial procedure was coarctoplasty and the Damus-Kaye-Stansel procedure with modified Blalock-Taussig shunt. The second procedure was intraventricular repair (Kawashima procedure), Damus-Kaye-Stansel take-down and the reuse of native aortic and pulmonary valves 19 and 25 months later. Both patients survived the operations and postoperative hemodynamics were excellent at both 28 and 59 months follow-ups.

Off-pump coronary artery bypass (OPCAB) with complete avoidance of aortic manipulation may further reduce perioperative morbidity in addition to the benefits achieved by avoiding cardiopulmonary bypass and cardioplegic arrest.We prospectively analyzed 222 consecutive patients with multivessel disease who underwent OPCAB without aortic manipulation (group I), and compared them with 123 consecutive patients who underwent OPCAB using additional free arterial or saphenous vein grafts that were anastomosed on the ascending aorta (group II) and 76 consecutive patients who underwent on-pump conventional coronary artery bypass grafting (group III).No significant differences were noted in operative mortalities among the three groups (2/222, 3/123, and 2/76 in groups I, II, and III, respectively; p = NS). Fewer distal anastomoses were done in group I compared with groups II and III (3.2 +/- 0.9, 3.5 +/- 0.8, and 3.7 +/- 0.9 in groups I, II, and III, respectively; p0.001). No differences were noted in the incidences of postoperative morbidities such as mediastinitis, pulmonary complication, and reoperation for bleeding. The incidences of stroke, atrial fibrillation, and acute renal failure were significantly lower in group I than in group III (p0.05), although there were no significant differences between groups II and III. The incidence of perioperative myocardial infarction was significantly lower in group I than in groups II and III (p0.05), although there was no significant difference between groups II and III.Our results demonstrate that OPCAB with complete avoidance of aortic manipulation may further reduce the incidence of perioperative morbidities such as stroke, atrial fibrillation, acute renal failure, and perioperative myocardial infarction.

During nasotracheal intubation, the tracheal tube passes through either the upper or lower pathway in the nasal cavity, and it has been reported to be safer that the tracheal tube passes though the lower pathway, just below the inferior turbinate. We evaluated the use of a nasogastric tube as a guide to facilitate tracheal tube passage through the lower pathway, compared with the 'conventional' technique (blind insertion of the tracheal tube into the nasal cavity). A total of 60 adult patients undergoing oral and maxillofacial surgery were included in the study. In 20 out of 30 patients (66.7%) with the nasogastric tube-guided technique, the tracheal tube passed through the lower pathway, compared with 8 out of 30 patients (26.7%) with the 'conventional' technique (p = 0.004). Use of the nasogastric tube-guided technique reduced the incidence and severity of epistaxis (p = 0.027), improved navigability (p = 0.034) and required fewer manipulations (p = 0.001) than the 'conventional' technique.

We present an alternative technique to the modified Fontan procedure used in a 3-year-old boy who had complex heart defects with bilateral superior vena cava and apicocaval juxtaposition. The left superior vena caval pathway was used behind the ventricle to connect the inferior vena cava to the pulmonary artery. We proved the technical feasibility of this with good midterm results at the 5-year follow-up angiography.

UNLABELLED Left ventricular (LV) thrombus is one of the risk factors for systemic thromboembolism. The aims of this study were to compare the long-term clinical outcomes of LV thrombus using current therapeutics, anticoagulation, operative treatment, and antiplatelet agents and to identify independent predictors of systemic thromboembolism. METHODS We screened 86,374 patients for intracardiac thrombus in the electronic medical records and imaging databases. Records of 62 patients with LV thrombus, diagnosed between May 2003 to November 2011, were comprehensively reviewed regarding baseline characteristics, imaging data and thrombus outcomes, thromboembolic events and treatment complications by treatment group. RESULTS The majority (80.6%) had ischemic etiology. Systemic thromboembolism developed in 18 patients; 8 (45%) were post-treatment thromboembolisms while 10 events occurred before treatment began. No post-treatment thromboembolism occurred in the operative treatment group; in contrast, 7 post-treatment thromboembolisms occurred in anticoagulation group (17%) (Log rank p= 0.175). Independent predictors of post-treatment thromboembolism were dilated cardiomyopathy (HR 61.30, p= 0.001), previous cerebrovascular events (HR 7.06, p= 0.042), female gender (HR 7.11, p= 0.031), and echocardiographic left ventricular end-diastolic diameter (HR 1.15, p= 0.047). CONCLUSIONS In this study, the rate of post-treatment thromboembolism was not significantly different among the treatment groups; however, operative treatment tended towards less post-treatment thromboembolism than other treatment groups.

BACKGROUND Acute normovolemic hemodilution (ANH) is currently performed during thoracoabdominal aortic surgery. However, the effects of ANH on spinal cord ischemic injury are currently unknown. Because hemodilution below a certain level of hematocrit (Hct) aggravates the neurological damage after cerebral ischemia, we hypothesized that ANH may increase neurological damage after spinal cord ischemia. The aim of these experiments was to determine the effects of ANH on spinal cord ischemic injury. METHODS Thirty male Sprague-Dawley rats were randomly assigned to 1 of the following 3 groups: no hemodilution (group C), target Hct level of 30% (group HD30), and target Hct level of 25% (group HD25). ANH was performed upon withdrawal of blood and simultaneous replacement with the same volume with hydroxyethyl starch. Spinal cord ischemia and reperfusion were induced by using a balloon-tipped catheter placed in the descending thoracic aorta, and changes in mean arterial blood pressure were recorded. Neurological function of the hindlimbs was evaluated for 7 days and recorded using a motor deficit score (MDS) (0 = normal; 5 = complete paraplegia). The number of motor neurons within the spinal cord was counted after final MDS evaluation. RESULTS Group HD25 developed hypotension during the latter part of the ANH procedure. Group C and group HD30 experienced 3 minutes of reperfusion hypotension, whereas 6 minutes of hypotension was observed in group HD25. Two rats in group HD25 died during the experimental period. Seven days after reperfusion, the MDS of group C, group HD30, and group HD25 was 1.0 (0.5-2.0), 1.0 (0.5-2.0), and 4.0 (2.8-4.2) (median [95% confidence interval]), respectively. Group HD25 showed significantly higher MDS compared with group C (corrected P = 0.0018; 95% CI for median difference = 1.0-3.5). Motor neuron numbers in the anterior horns of group C, group HD30, and group HD25 were 26.5 (25.0-27.5), 23.5 (22.0-26.5), and 12.5 (8.4-16.6) (median [95% CI]), respectively. Motor neuron numbers of group HD25 were significantly lower than those of group C (corrected P < 0.0001; 95% CI for median difference = 9.0-18.0). CONCLUSION The results of the present study indicate that intraoperative ANH to an Hct of 25%, combined with coincident hypotension, caused a delayed recovery of baseline mean arterial blood pressure during the reperfusion period and aggravated neurological outcome after spinal cord ischemia.

Suitability rate of endovascular aneurysm repair (EVAR) and the anatomic features causing unsuitability have not been well determined in Asian patients who have abdominal aortic aneurysm (AAA). In a single Korean center, a total of 191 patients with abdominal aortic aneurysm (maximal diameter ≥ 4 cm) were identified. Aortoiliac morphologic characteristics in contrast-enhanced computed tomography images were retrospectively reviewed to determine suitability for EVAR with four FDA-approved stent-grafts. AAA was considered ideally suitable for EVAR in 46.6% of patients. The most frequent causes for unsuitability were common iliac artery (CIA) aneurysm (61.8%) and excessive neck angulation (52.9%). Problems such as small and/or short neck and small access were found in minor incidences. If CIA aneurysm is dealt by overstenting with sacrifice of internal iliac artery, suitability rate can increase to 65%. Larger aneurysms were more frequently unsuitable for EVAR and had more chance of having multiple unfavorable features. In conclusion, the overall feasibility rate for EVAR in Korean patients was not different from that in Western patients. However, considering the difference in the major causes of unsuitability, more attention has to be paid to neck angulation and CIA aneurysm to provide EVAR for more Korean patients especially who have large aneurysm.

A lot of anti-diabetic agents using natural plants have been extensively studied. Ginsenosides are known to be used as a remedy for diabetes in Asian countries and American Societies. Diabetic nephropathy is a major complication of diabetes mellitus. Extracellular matrix in mesangial cells is mainly composed of fibronectin and the increase of fibronectin is a hallmark of diabetic nephropathy. Protopenaxadiol (PPD) is a major component of total ginseng. Thus, we examined the regulatory mechanism of PPD derivatives-induced preventive effect of fibronectin expression in mesangial cells cultivated under diabetic condition. In present study, ginsenoside Rb1 prevented the high glucose-induced increase of fibronectin expression in mesangial cells. Ginsenoside Rb2 and Rg3 also mildly inhibited it. However, ginsenoside Rc and Rd did not prevent the high glucose-induced increase of fibronectin expression in mesangial cells. In addition, ginsenoside Rb1 prevented high glucose-induced phosphorylation of p44/42 mitogen activated protein kinase (MAPK), p38 MAPK, JNK/SAPK, and Akt. These results suggest that ginsenoside Rb1 is the most powerful component of PPD derivatives. In conclusion, ginsenoside Rb1 prevented high glucose-induced increase of fibronectin expression via the inhibition of MAPK-Akt signaling cascade.

Recent studies have suggested that percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (LMCA) disease renders outcomes comparable to those from coronary artery bypass grafting (CABG). It is necessary to stratify individual patient risk and select the optimal revascularization strategy. We compared the clinical outcomes of patients with unprotected LMCA disease who had undergone PCI with drug-eluting stents or CABG. We identified 462 patients who were treated from January 2003 to December 2006 for unprotected LMCA or LMCA-equivalent disease: 257 had undergone CABG and 205 had undergone PCI with drug-eluting stents. Analyses using propensity scores were performed to minimize the selection bias in the present observational study. After a median follow-up of 33.5 months, no significant difference was found between the CABG and PCI groups in the risk of death (12.1% vs 14.1%, respectively; p = 0.428) or the risk of a composite of death, myocardial infarction, or cerebrovascular accident (17.5% vs 20.0%, respectively; p = 0.434). The rate of major adverse cardiac and cerebrovascular events was significantly lower in the CABG group than in the PCI group (21.8% vs 35.1%, respectively; p = 0.001); the difference was mainly driven by a decrease in the rate of repeat revascularizations (5.1% vs 22.4%; p

Background/Aims: Depending on the specific definition, acute kidney injury (AKI) occurs in 7–40% of patients undergoing cardiac surgery. Even small changes in serum creatinine (SCr) levels are associated with increased mortality after cardiac surgery. However, there are no current methods for preventing AKI after cardiac surgery. Erythropoietin (EPO) has been shown to elicit tissue-protective effects in various experimental models. In this pilot trial, we evaluated the effectiveness of EPO in the prevention of AKI after coronary artery bypass grafting (CABG). Methods: 71 patients scheduled for elective CABG randomly received either 300 U/kg of EPO or saline intravenously before surgery. AKI was defined as a 50% increase in SCr levels over baseline within the first 5 postoperative days. Estimated glomerular filtration rate (eGFR) was calculated from the Cockcroft-Gault equation. Results: Of 71 patients, 13 developed postoperative AKI: 3 of the 36 patients in the EPO group (8%) and 10 of the 35 patients in the placebo group (29%; p = 0.035). The increase in postoperative SCr concentration and the decline in postoperative eGFR were significantly lower in the EPO group than in the placebo group. Conclusions: In our small, pilot trial, prophylactic administration of EPO prevents AKI and improves postoperative renal function. These data are preliminary and require confirmation in a larger clinical trial.

Background Controversies exist regarding the pathogenesis and adequate management of intramural hematoma (IMH) of the aorta that has been commonly defined as a dissection without intimal tear. Recent studies reported that intimal defects are found in some patients diagnosed as IMH. We aimed to investigate the prevalence of such cases in surgically treated patients. Methods Preoperative and postoperative computed tomographic (CT) scan images were retrospectively reviewed for 37 patients who underwent surgery for Stanford type A acute IMH. Operative findings were also reviewed from the medical records. Results In 18 patients (48.6%), intimal defects were suggested in preoperative computed tomography (CT). During surgery, 27 patients (73.0%) had small intimal defects in the ascending aorta or arch, while 14 of them (51.9%) did not have preoperative CT findings suggestive of intimal defects. In 18 patients, the defects were located in the arch or distal ascending aorta, where they would not have been found if not inspected under total circulatory arrest. In all patients, the identified intimal defects were included in the aortic resection, or locally closed. Follow-up CT done at 4 months or longer after surgery showed that the IMH in the descending aorta disappeared or markedly improved in all patients. Conclusions On the basis of our results, we think that a large proportion of IMH may have a similar pathogenic mechanism as classic dissection and the conventional definition of IMH should be changed. For type A lesions treated with surgery, we recommend thorough inspection of the ascending aorta and the arch under hypothermic circulatory arrest.