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Although surgical approaches for infected or failing cardiac implantable electronic device (CIED) leads are more invasive than transvenous approaches, they are still required for patients considered unsuitable for transvenous procedures. In this study, surgical management with transvenous equipment for CIED complications was examined in patients unsuitable for transvenous lead extraction.Methods and Results: We retrospectively examined 152 consecutive patients who underwent CIED extraction between April 2009 and December 2021 at the Department of Cardiovascular Surgery, Nippon Medical School. Nine patients (5.9%; mean [±SD] age 61.7±16.7 years) who underwent open heart surgery were identified as unsuitable for the isolated transvenous approach. CIED types included 5 pacemakers and 4 implantable cardioverter-defibrillators; the mean [±SD] lead age was 19.5±7.0 years. Indications for surgical management according to Heart Rhythm Society guidelines included failed prior to transvenous CIED extraction (n=6), intracardiac vegetation (n=2), and severe lead adhesion (n=1). Transvenous CIED extraction tools were used in all patients during or before surgery. Additional surgical procedures with CIED extraction included epicardial lead implantation (n=4) and tricuspid valve repair (n=3). All patients were discharged; during the follow-up period (mean 5.7±3.7 years), only 1 patient died (non-cardiac cause).Surgical procedures and transvenous extraction tools were combined in the removal strategy for efficacious surgical management of CIED leads. Intensive surgical procedures were safely performed in patients unsuitable for transvenous extraction.

The efficacy of anti-programmed celldeath protein 1 treatment in patients with urothelial carcinoma (UC) with molecular subtypes of histological variants has not been investigated. This study aimed to examine the impact of histological variants classified according to molecular subtypes on clinical outcomes in patients with platinum-resistant metastatic UC treated with pembrolizumab.Data of 168 patients with metastatic UC who received intravenous pembrolizumab after platinum-based chemotherapy between December 2017 and November 2020 were retrospectively reviewed. Relationships between histological variant type (basal or luminal molecular subtypes) and survival outcome and response to immunotherapy were examined. Clinicopathological factors were analyzed using the Cox proportional hazards model.UC with histological variants was identified in 19 (11.3%) cases (basal subtype in 12; luminal subtype in 7). The median age of the patients was 72.5 years (range=40-89 years). The performance status was 0-1 in 151 (89.9%) patients. Liver metastasis was detected in 44 (26.2%) patients. The median progression-free survival was 3.5 months (range=0.5-34.3 months). Treatment with immune checkpoint inhibitors resulted in an overall mean survival (from the start of treatment) of 8.1 months (range=1.2-34.3 months). Patients with basal-type UC had significantly shorter progression-free survival and cancer-specific survival than those with pure UC (p=0.010 and p=0.035, respectively). A complete response was observed in eight patients (seven with pure UC, one with basal type).The basal histological variant might be a potential prognostic indicator in patients with platinum-resistant metastatic UC treated with pembrolizumab.

Tricuspid valve insufficiency rarely follows a blunt chest trauma. When the tricuspid valve is solely injured, the cardiac trauma may stay asymptomatic and tolerable, which often makes it difficult to determine the indication for surgery. We report a case of a patient with tricuspid regurgitation secondary to trauma due to a motorcycle accident. The patient was initially asymptomatic, but shortness of breath emerged two years after the accident. He underwent the tricuspid valve repair with chordae reconstruction and annuloplasty via lower partial sternotomy. We advocate that early surgical intervention prevents right heart failure, atrial fibrillation, and valve replacement.

Objective: To determine pulmonary functional changes that predict early clinical outcomes in valve surgery requiring long cardiopulmonary bypass (CPB). Methods: This retrospective study included 225 consecutive non-emergency valve surgeries with fast-track cardiac anesthesia between January 2014 and March 2020. Blood gas analyses before and 0, 2, 4, 8, and 14 h after CPB were investigated. Results: Median age and EuroSCORE II were 71.0 years (25–75 percentile: 59.5–77.0) and 2.46 (1.44–5.01). Patients underwent 96 aortic, 106 mitral, and 23 combined valve surgeries. The median CPB time was 151 min (122–193). PaO2/FiO2 and AaDO2/PaO2 significantly deteriorated two hours, but not immediately, after CPB (both p &lt, 0.0001). Decreased PaO2/FiO2 and AaDO2/PaO2 were correlated with ventilation time (r2 = 0.318 and 0.435) and intensive care unit (ICU) (r2 = 0.172 and 0.267) and hospital stays (r2 = 0.164 and 0.209). Early and delayed extubations (&lt, 6 and &gt, 24 h) were predicted by PaO2/FiO2 (377.2 and 213.1) and AaDO2/PaO2 (0.683 and 1.680), measured two hours after CPB with acceptable sensitivity and specificity (0.700–0.911 and 0.677–0.859). Conclusions: PaO2/FiO2 and AaDO2/PaO2 two hours after CPB were correlated with ventilation time and lengths of ICU and hospital stays. These parameters suitably predicted early and delayed extubations.

Background: Patients on hemodialysis are at high risk of adverse cardiac events after coronary artery bypass grafting (CABG). The aim of this study is to know whether CABG with complete revascularization and similar graft selection can provide equivalent long-term benefits for patients on and not on hemodialysis. Methods: Between 2004 and 2018, 746 patients underwent isolated CABG, of which 106 were on hemodialysis. Propensity matching on baseline characteristics, graft types and on/off-pump CABG was performed to compare clinical outcomes between patients on (n = 102) and not on (n = 102) hemodialysis. Results: Complete revascularization was achieved in all patients. The mean follow-up was 112.5 ± 46.6 months. Off-pump rates (hemodialysis vs non-hemodialysis, 93/102 vs 94/102, p > 0.999) and graft selections (distal anastomoses: 3.7 ± 1.4 vs 3.8 ± 1.5, p = 0.377, ITA grafts: 1.4 ± 0.6 vs 1.5 ± 0.6, p = 0.560, arterial grafts: 1.9 ± 0.9 vs 2.0 ± 0.8, p = 0.658, vein grafts: 0.69 ± 0.63 vs 0.65 ± 0.70, p = 0.513) were well balanced between the groups. Hospital mortality was higher in patients on hemodialysis than in those not on hemodialysis (5/102 vs 1/102, p = 0.212). The Kaplan-Meier analysis revealed that cardiac death (without non-cardiac causes) was significantly more common in patients on hemodialysis than in those not on hemodialysis (p = 0.018). However, there were no significant differences in deaths due to ischemic heart disease (p = 0.327), repeated revascularization (p = 0.542), myocardial infarction (p = 0.783), and heart failure requiring admission (p = 0.371). Conclusion: CABG with complete revascularization and similar graft selection provides equivalent long-term benefits with regard to the prevention of adverse cardiac events due to ischemic heart disease in patients on and not on hemodialysis.

Early extubation (EEx) after cardiac surgery has been essentially studied in patients with short cardiopulmonary bypass (CPB). Whether preoperative spirometry can predict EEx remains controversial.To investigate whether EEx can be a goal and predicted by preoperative spirometry in valve surgery requiring long CPB.Nonemergent consecutive 210 patients who underwent valve surgery from January 2014 to August 2019 were investigated retrospectively.EEx (8 h) was achieved in 93 (44.3%) patients without increasing adverse events. Patients with EEx had shorter ICU and hospital stays than those without EEx. Multivariate analysis showed that higher estimated glomerular filtration rate and mitral valve repair were significant protective factors for EEx. Conversely, moderate and severe chronic obstructive pulmonary disease defined by spirometry, longer operation, CPB, and aortic cross-clamp time were significant risk factors.EEx should be the goal in current valve surgery. Preoperative spirometry is a significant predictor.

Background:Cerebrovascular disease (CVD) with brain hypoperfusion is a strong risk factor for stroke. However, how this pathology influences long-term outcomes after coronary artery bypass graft (CABG) surgery is not known.Methods:Magnetic resonance imaging/angiography (MRI/A) of the neck and brain was performed in 318 out of 575 consecutive CABG patients between May 2005 and April 2018. Critical CVD with chronic hypoperfusion was defined as multiple severe stenoses (⩾70%) and/or occlusion in the carotid and/or vertebral systems associated with reduced collateral flow due to severe contralateral and/or circle of Willis lesion. Fifty patients were identified to have this pathology (early results were previously reported). The entire cohort was followed up for 83.6 ± 53.7 months. Carotid endarterectomy was considered for symptomatic patients. Propensity matching was performed to compare long-term outcomes between patients with and without critical CVD.Results:Patients with critical CVD at follow-up displayed significantly higher incidences of stroke than those without critical CVD (p=0.007), with an extremely high final incidence (approximately 40% at 8 years). However, survival (p=0.623) and incidences of major adverse cardiac events (MACE: myocardial infarction, coronary revascularization and all causes of death) (p=0.881) were similar. The Cox hazard model revealed that critical CVD was the strongest risk factor for stroke (p=0.000; hazard ratio 6.572; 95% confidence interval 2.657–16.258) while not affecting survival and MACE.Conclusion:Critical CVD was the strongest risk factor for long-term stroke after CABG. However, survival and MACE-free rates were equivalent in patients with critical CVD and those without critical CVD.

The authors present the first case report of pre-surgical axitinib treatment on primary renal tumor and vena cava thrombus. We report the case of a 78-year-old woman with renal cell carcinoma and inferior vena cava tumor thrombus, successfully downstaged with pre-surgical therapy with axitinib. A significant objective response was observed for tumor size and thrombus. After initiation of axitinib therapy, computed tomography showed a decrease, from 57 to 51 mm, in the maximal renal tumor diameter. The tumor thrombus had shortened to 42 mm and had moved to the inferior hepatic vein (Levels 4-3), thereby obviating the need for thoracotomy. The patient finally accepted surgical treatment. Our case was enabled to perform less surgery for advanced renal cell carcinoma with tumor thrombus using axitinib as a pre-surgical therapy.

Objectives To evaluate the utility of diameter-axis-polar nephrometry score to evaluate partial nephrectomy outcomes. Methods Renal tumors of 127 patients with a functional contralateral kidney who underwent partial nephrectomy were scored using the diameter-axis-polar and R.E.N.A.L nephrometry scores. The mean tumor diameter was 2.9 cm (range 1.0–8.0 cm) and warm ischemic time was 27.3 min (range 12–46 min). All patients underwent 99mTc- mercaptoacetyltriglycine renal scintigraphy preoperatively and 6 months postoperatively to assess effective renal plasma flow. We compared nephrometry scores with estimated glomerular filtration rate, effective renal plasma flow and ischemic time. Results The mean serum creatinine level was 0.84 mg/dL preoperatively and 0.93 mg/dL at 6 months postoperatively. The mean estimated glomerular filtration rate decreased from 74.2 to 66.9 mL/min/1.73 m2. Effective renal plasma flow of the operated kidney decreased to 73.5% from baseline (from 157.0 to 114.3 mL/min/1.73 m2). Univariate and multivariate analyses showed that diameter-axis-polar score had a stronger association with the percent change in estimated glomerular filtration rate, effective renal plasma flow in the treated kidney and ischemia time compared with the R.E.N.A.L score. Conclusions Diameter-axis-polar nephrometry score is a useful tool for the assessment of small renal tumors amenable to partial nephrectomy, and it better predicts postoperative functional changes and ischemic time compared with the R.E.N.A.L nephrometry score.

A 38 year-old male was referred to our hospital due to bilateral hydronephrosis. Cystoscopy revealed multiple edematous papillary tumors that exist on the prostatic urethra, bladder neck, trigone, and lateral wall on both sides. He underwent a transurethral resection of bladder tumors. The pathological diagnosis was cystitis glandularis. He was given steroid orally for 6 months and had no sign of recurrence after 2 years.

To evaluate the utility of diameter-axis-polar nephrometry score to evaluate partial nephrectomy outcomes.Renal tumors of 127 patients with a functional contralateral kidney who underwent partial nephrectomy were scored using the diameter-axis-polar and R.E.N.A.L nephrometry scores. The mean tumor diameter was 2.9 cm (range 1.0-8.0 cm) and warm ischemic time was 27.3 min (range 12-46 min). All patients underwent (99m)Tc- mercaptoacetyltriglycine renal scintigraphy preoperatively and 6 months postoperatively to assess effective renal plasma flow. We compared nephrometry scores with estimated glomerular filtration rate, effective renal plasma flow and ischemic time.The mean serum creatinine level was 0.84 mg/dL preoperatively and 0.93 mg/dL at 6 months postoperatively. The mean estimated glomerular filtration rate decreased from 74.2 to 66.9 mL/min/1.73 m(2) . Effective renal plasma flow of the operated kidney decreased to 73.5% from baseline (from 157.0 to 114.3 mL/min/1.73 m(2)). Univariate and multivariate analyses showed that diameter-axis-polar score had a stronger association with the percent change in estimated glomerular filtration rate, effective renal plasma flow in the treated kidney and ischemia time compared with the R.E.N.A.L score.Diameter-axis-polar nephrometry score is a useful tool for the assessment of small renal tumors amenable to partial nephrectomy, and it better predicts postoperative functional changes and ischemic time compared with the R.E.N.A.L nephrometry score.

A 30-year-old man presented with micturition pain and was diagnosed with a submucosal tumor in the right wall of the bladder with metastasis to the right obturator lymph node. Transurethral resection led to a diagnosis of invasive malignant pheochromocytoma. Radical cystectomy, neobladder reconstruction and bilateral iliac lymph node dissection were performed. Genetic analysis revealed succinate dehydrogenase B-associated hereditary pheochromocytoma/paraganglioma syndrome. 10 months after the operation, he had no evidence of recurrence.

Negative bias on transfer gate in 4-transistor CMOS imager pixel is an efficient way to reduce dark current generated at the Si-SiO2 interface. But further lowering of negative bias increases dark current noise. In this paper, detailed cause analysis of dark current noise generated when negative bias is applied and the key technology to reduce the dark current noise are shown. The dark output level of hot pixel follows a Trap-Assisted-Tunneling (TAT) dark current electric field dependency. Device simulation shows that the generation of high electric field is attributed to the large voltage difference between the high concentration hole accumulation layer under negatively biased transfer gate and n- layer of FD edge along transfer gate. The reduction of dark current in FD is experimentally observed when the n- dopnat concentration at FD edge is decreased and when a gate insulator thickness is increased. The results show that the mechanism of the dark current increase is Gate-Induced-Leak (GIL) TAT generated by high electric field at the edge of a FD along negatively biased transfer gate. The reduction of the maximum electric filed at the FD edge by reducing FD dopant concentration is one of the key to suppress the GIL - TAT dark current.

Photoluminescence (PL) spectra induced by ultraviolet photons were measured for amorphous hafnia and zirconia deposited by plasma-enhanced chemical-vapor deposition (PECVD), amorphous hafnia deposited by pulse laser deposition, and crystalline yttria-stabilized zirconia. Two kinds of samples were prepared for both hafnia and zirconia deposited by PECVD using different source alkoxides in different deposition chambers. A PL peak was observed around 2.8eV similarly in all hafnia and zirconia samples, irrespective of the difference in crystallinity, oxygen deficiency, source alkoxide, deposition method, or the substrate material. The decay profile of this PL is also similar in all the samples. These facts clearly show that neither impurities, oxygen vacancy, nor defects at the interface between the sample and the substrate are responsible for the PL. It is a luminescence inherent in hafnia and zirconia and is most likely due to radiative recombination between localized states at the band tails. When the samp...