Search

Objectives: Mesenteric malperfusion in acute aortic dissection remains a life-threatening complication with no standardized treatment strategy. This study aimed to describe and evaluate the outcomes of our integrated approach combining exploratory laparotomy, immediate mesenteric reperfusion, and central aortic repair., Methods: We retrospectively reviewed patients with acute aortic dissection with a preoperative diagnosis of mesenteric malperfusion who were treated between August 2011 and November 2022. Our surgical approach was to establish cardiopulmonary bypass, followed by exploratory laparotomy with mesenteric artery flow assessment using Doppler ultrasound and direct perfusion if needed, central aortic repair, and subsequent mesenteric artery reconstruction. The primary end-point was the 30-day operative mortality., Results: Among 217 patients with acute aortic dissection, 12 (5.5%) had mesenteric malperfusion on preoperative computed tomography. Ten patients underwent exploratory laparotomy, where Doppler ultrasonography revealed reduced mesenteric blood flow in five patients (2.3% of the total 217 patients). These patients underwent direct perfusion of the mesenteric artery via a side branch of the cardiopulmonary bypass circuit. Doppler ultrasound confirmed the restoration of mesenteric blood flow in all perfused patients. No bowel resections were required. The operative mortality in patients with mesenteric malperfusion was 20%. The causes of death were stroke (n = 1) and acute myocardial infarction (n = 1)., Conclusions: Our integrated surgical strategy combining central aortic repair with concurrent exploratory laparotomy and immediate mesenteric perfusion demonstrated technical feasibility in managing mesenteric malperfusion during aortic repair. Further prospective studies with larger cohorts are warranted to validate these findings., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objective Patients undergoing transcatheter aortic valve implantation (TAVI) are generally older and frailty is therefore an important clinical issue. The baseline degree of frailty is associated with the prognosis in patients undergoing TAVI; however, the incidence of in-hospital frailty progression and its influencing factors have not yet been elucidated. Methods This observational, single-center study retrospectively evaluated 281 patients who underwent TAVI. The degree of frailty at baseline and discharge was evaluated using the Clinical Frailty Scale (CFS). In-hospital frailty progression was defined as an increase of at least one level in the CFS score at discharge from baseline, and predictors of frailty progression were assessed. Results The median baseline CFS score was 4.0 (interquartile range: 3.0-4.0). In-hospital frailty progression was observed in 49 patients (17.4%). No significant differences were observed in age, sex, comorbidities, or surgical risk scores between patients with and without frailty progression. Patients with frailty progression experienced stroke more frequently during hospitalization than those without (12.2% vs. 1.3%, p=0.001). A multivariable logistic analysis showed that in-hospital stroke was a significant predictor of frailty progression (odds ratio, 10.7; 95% confidence interval: 2.34-49.2, p=0.002). Patients with frailty progression had a longer hospital stay than those without frailty progression [7.0 (4.0-17.0) vs. 4.0 (4.0-8.0) days, p=0.001]. Conclusion In-hospital frailty progression was not uncommon in patients undergoing TAVI. Stroke incidence was a significant influencing factor in frailty progression, whereas baseline comorbidities and surgical risks were not.

Open thoracic aortic surgery is believed to necessitate more intensive rehabilitation. This study aimed to compare the progress of postoperative rehabilitation between standard and delayed mobilization. A retrospective review was conducted on 199 patients who underwent isolated total aortic arch replacement via median sternotomy. Cases of in-hospital mortality and postoperative stroke were excluded. Based on the current guidelines for cardiovascular rehabilitation of the Japanese Circulation Society, patients were categorized into standard mobilization (could sit on the edge of bed within 2 days) and delayed mobilization (could not do so) groups. Rehabilitation progress was compared among both groups. Initial mobilization was delayed in 100 patients (delayed mobilization group), primarily because of respiratory failure (46.0%). Preoperative risk characteristics, including EuroSCORE II (median, 2.9 versus 3.5), were similar between the standard and delayed mobilization groups. The delayed mobilization group had longer operation (median, 6.1 versus 8.0 hours, P < 0.001) and cardiopulmonary bypass (median, 3.2 versus 4.1 hours, P < 0.001) times. Independent ambulation occurred earlier in the standard mobilization group (median, 6.0 versus 8.0 days, P < 0.001).In conclusion, early initiation of sitting on the edge of the bed within 2 days was associated with earlier independent ambulation during postoperative rehabilitation, which supports the current guidelines. Longer operation and cardiopulmonary bypass times were associated with delayed mobilization initiation, suggesting the need for more tailored approaches in such cases.

Bacterial infections on material surfaces are a serious public health concern worldwide. Although poly(vinyl alcohol) (PVA)-based materials have great potential as medical devices, they lack antibacterial properties on their surfaces and pose bacterial infection risks during implantation surgery. Copolymers containing antibacterial [2-(methacryloyloxy)ethyl]trimethylammonium chloride (METAC) units were used to modify the surfaces of chemically cross-linked water-insoluble PVA-based microfibers. The copolymers also had carboxy units that were used to react with the hydroxy group of the PVA-based microfibers via a simple thermal treatment at 135 °C. PVA-based materials containing METAC units exhibit significant swelling due to electrostatic repulsions. Because the copolymers were modified on the extreme surface of the microfibers, no difference in the diameters between unmodified microfibers (PM-fiber) and copolymers with METAC unit-modified microfibers (PM-METAC-fiber), in both the dry and swollen states, was observed. The viable bacterial cell numbers, which were evaluated by colony counting, decreased by exposure to the poly(METAC- co -methacrylic acid (MAAc)) aqueous solution or PM-METAC-fibers. The value of CFU/mL decreased to 0.1% (against B. subtilis ) and 3.9% (against E. coli ) after contact with the PM-METAC-fibers compared to the PM-fibers. The percentage of hemolysis against rabbit red blood cells was equivalent to that of the negative control, suggesting that PM-METAC-fibers can selectively exhibit antibacterial properties. This modification method can be applied to various PVA-based materials if hydroxy groups are present on their surface. This study provides a facile, cost-effective, and promising strategy to impart antibacterial properties to the surface of PVA-based materials without significantly affecting their physicochemical properties., Competing Interests: The authors declare no competing financial interest., (© 2024 The Authors. Published by American Chemical Society.)

Multiple hydrogels are developed for injection therapy after myocardial infarction, with some incorporating substances promoting tissue regeneration and others emphasizing mechanical effects. In this study, porosity and extracellular matrix-derived digest (ECM) are incorporated, into a mechanically optimized, thermoresponsive, degradable hydrogel (poly(N-isopropylacrylamide-co-N-vinylpyrrolidone-co-MAPLA)) and evaluate whether this biomaterial injectate can abrogate adverse remodeling in rat ischemic cardiomyopathy. After myocardial infarction, rats are divided into four groups: NP (non-porous hydrogel) without either ECM or porosity, PM (porous hydrogel) from the same synthetic copolymer with mannitol beads as porogens, and PME with porosity and ECM digest added to the synthetic copolymer. PBS injection alone is a control group. Intramyocardial injections occurred 3 days after myocardial infarction followed by serial echocardiography and histological assessments 8 weeks after infarction. Echocardiographic function and neovascularization improved in the PME group compared to the other hydrogels and PBS injection. The PME group also demonstrated improved LV geometry and macrophage polarization (toward M2) compared to PBS, whereas differences are not observed in the NP or PM groups versus control. These results demonstrate further functional improvement may be achieved in hydrogel injection therapy for ischemic cardiomyopathy by incorporating porosity and ECM digest, representing combined mechanical and biological effects., (© 2024 The Author(s). Advanced Healthcare Materials published by Wiley‐VCH GmbH.)

Aims: Impella has become a new option for mechanical circulatory support in patients with cardiogenic shock (CS); however, prognostic models for patients after Impella are lacking. We aimed to identify the factors that predict in-hospital mortality in patients with CS requiring Impella and develop a new risk prediction model., Methods and Results: We utilized the J-PVAD registry, which includes all cases where Impella was implanted in Japan. Two-thirds of the patients in the J-PVAD registry were randomly assigned to the derivation cohort (n = 1701), and the other third was assigned to the validation cohort (n = 850). A backward stepwise logistic regression model was developed to identify factors associated with in-hospital mortality. In the derivation cohort, 956 patients were discharged alive, and 745 patients (43.8%) died during hospitalization. Among 29 candidate variables, 12 were independently associated with in-hospital mortality and were applied as components of the risk model, including age, sex, body mass index, fulminant myocarditis aetiology, cardiac arrest in hospital, baseline veno-arterial extracorporeal membrane oxygenation use, mean arterial pressure, lactate, lactate dehydrogenase, total bilirubin, creatinine, and albumin levels. The comparison of predicted and observed in-hospital mortality according to the 7th quantiles using the J-PVAD risk score showed good calibration. The area under the curve for the J-PVAD risk score was 0.76 (95% confidence interval 0.73-0.78). In the validation cohort, the J-PVAD risk score showed good calibration and discrimination ability., Conclusions: The J-PVAD risk score can be calculated using variables easily obtained in routine clinical practice. It helps the accurate stratification of mortality risk and facilitates clinical decision-making., (© 2024 The Author(s). European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Objectives: Type A acute aortic dissection (TAAAD) is a life-threatening condition often requiring emergency surgery, with approximately 30% of patients needing reoperation. This study aimed to identify predictors of long-term aortic events from early postoperative computed tomography (CT) examinations., Methods: A total of 336 cases underwent TAAAD surgery at two institutions between 2002 and 2018. Of these, 302 patients received CT examinations immediately after initial TAAAD surgery. Predictors of aortic events were evaluated from these early postoperative CT exams. Aortic events were defined as any events involving aortic-related death, open surgery, reoperation, endovascular stenting, or thoracic aorta diameter enlargement to ≥ 55 mm., Results: Excluding 34 in-hospital deaths (10.1%; 34/336), the 1-, 5-, and 10-year actuarial survival rates after primary TAAAD surgery were 98.2%, 88.6%, and 81.7%, respectively. Over a mean follow-up period of 7.4 ± 5.1 years, 67 aortic events (proximal: 19, distal: 45, both: 3) were observed. Freedom from proximal aortic events was 98.6%, 93.9%, and 85.2% at 1, 5, and 10 years, respectively. Proximal anastomosis new entry was identified as a significant risk factor for aortic events, with a 92% vs. 42% incidence at 10 years (p < 0.001). Freedom from distal aortic events was 99.6%, 84.5%, and 67.2% at 1, 5, and 10 years, respectively. A false/true area ratio greater than 1 and distal anastomosis new entry were significant risk factors for aortic events (low-risk group: 83.3% vs. high-risk group: 42.3% at 10 years, p < 0.001)., Conclusions: Detailed analysis of early postoperative CT scans following primary TAAAD surgery may help identify predictors of subsequent aortic events, potentially improving long-term patient management and outcomes., (© 2024. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Heart transplantation is considered to be the best treatment for severe heart failure refractory to medical therapy, improving patients' survival and quality of life (QOL). However, the number of donors is smaller than the number of registered applicants for heart transplantation, which increases every year, and the waiting period for heart transplantation has been extended to more than 1700 days by 2022. Since 2011, reimbursement for the implantable left ventricular assist device (iLVAD) was established. The numbers of the iLVAD patients have been increasing year by year. Patients are managed at home with an iLVAD and can live with their families and even return to work, depending on the situation. On the other hand, self-management at home, including caregivers, is important for a safe life. Home management beyond 5 years is becoming more common due to long waiting time for transplant. This article outlines the important aspects of patient management for long-term support. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 62-66), with some modifications., (© 2024. The Japanese Society for Artificial Organs.)

Gold standard cannulation for peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is from the femoral artery and vein by using ultrasound guided puncture technique percutaneously. The Seldinger technique by using the guide wire is the major approach to place the cannula. Direct cut-down exposure technique is another option if the percutaneous approach is difficult. The size selection of the cannula is also important to get sufficient flow for peripheral VA-ECMO. If the lower limb had ischemia, the extra distal perfusion should be added. Central ECMO by perfusing the ascending aorta and drainage from the right atrium is the emergent option when the circulatory problem had occurred in the intensive care unit( ICU) after cardiac surgery. In patients who cannot come off cardiopulmonary bypass, the ordinary cannulation using the ascending aorta and superior venous cava and inferior venous cava for central ECMO should be continued. Complications associated with VA-ECMO insertion include bleeding, vascular injury, retroperitoneal injury, and hematoma due to accidental puncture, and leg ischemia. There are various approaches to VA-ECMO, and it is important to fully understand and master the characteristics of each ones.

A 31-year-old man with a HeartMate 3 was admitted with a "Driveline Communication Fault" alarm due to liquid infiltration. Eleven months earlier, the connector between the modular and pump cables had gotten wet when he was taking a shower. The cable connector was dried immediately, and no alarm had been observed during follow-up. Subsequently, the modular cable and system controller were replaced, with corrosion found on the modular cable connector. The "Communication Fault" alarm recurred, and complete damage to the communication cables was discovered. The pump was replaced, and the removed pump cable connector showed corrosion as well. If the driveline connector gets wet, the multidisciplinary team should discuss if it should be immediately disconnected and dried, averting the need for future pump replacements due to corrosion., (© 2024. The Japanese Society for Artificial Organs.)

Apoptosis inhibitor of macrophage (AIM) is known to induce apoptosis resistance in macrophages and to exacerbate chronic inflammation, leading to arteriosclerosis. The role of AIM in aortic aneurysm (AA) remains unknown. This study examined the effects of an anti-AIM antibody in preventing AA formation and progression. In apolipoprotein E-deficient mice, AA was induced by subcutaneous angiotensin II infusion. Mice were randomly divided into two groups: (i) AIM group; weekly anti-murine AIM monoclonal antibody injection (n = 10), and (ii) IgG group; anti-murine IgG antibody injection as control (n = 14). The AIM group, compared with the IgG group, exhibited reduced AA enlargement (aortic diameter at 4 weeks: 2.1 vs. 2.7 mm, respectively, p = 0.012); decreased loss of elastic lamellae construction; reduced expression levels of IL-6, TNF-α, and MCP-1; decreased numbers of AIM-positive cells and inflammatory M1 macrophages (AIM: 1.4 vs. 8.0%, respectively, p = 0.004; M1 macrophages: 24.5 vs. 55.7%, respectively, p = 0.017); and higher expression of caspase-3 in the aortic wall (22.8 vs. 10.5%, respectively, p = 0.019). Our results suggest that administration of an anti-AIM antibody mitigated AA progression by alleviating inflammation and promoting M1 macrophage apoptosis., (© 2024. The Author(s).)

Percutaneous mechanical circulatory support utilizing micro-axial flow pumps, such as the Impella group of devices, has become a life-saving technique in the treatment of refractory cardiogenic shock, with ever-increasing success rates. A 30-year-old man presented with acute decompensated heart failure and a severely reduced left ventricular ejection fraction (17%). Despite initial treatment with inotropic drugs and intra-aortic balloon pump support, his hemodynamic status remained unstable. Transition to Impella CP mechanical circulatory support was made on day 6 owing to persistently low systolic blood pressure. A significant decline in platelet count prompted suspicion of heparin-induced thrombocytopenia (HIT), later confirmed by positive platelet-activated anti-platelet factor 4/heparin antibody and a 4Ts score of 6 points. Argatroban was initially used as the purge solution, but owing to complications, a switch to Impella 5.0 and a bicarbonate-based purge solution (BBPS) was performed. Despite additional veno-arterial extracorporeal membrane oxygenation support on day 24, the patient, aiming for ventricular assist device treatment and heart transplantation, died from infection and multiple organ failure. Remarkably, the Impella CP continued functioning normally until the patient's demise, indicating stable Impella pump performance using BBPS. This case highlights the usefulness of BBPS as an alternative to conventional Impella heparin purge solution when HIT occurs., (© 2024. The Author(s).)

We assessed the applicability of high-performance liquid chromatography (HPLC) to the official testing method for the migration of caprolactam (CPL) from food utensils, containers, and packaging made from polyamide (PA). Hydrophilic interaction chromatography (HILIC) columns coated with unmodified silica, carbamoyl, and aminopropyl were used. Water and acetonitrile (ACN) were used as the mobile phase, and the analytical conditions were optimized. The test solution was diluted 10-fold with ACN, and standard solutions were prepared using 98% ACN. We validated using HPLC as limit testing and quantitative testing methods. Accuracy parameters corresponding to trueness, repeatability, and reproducibility (as intermediate precision) satisfied the target values in both cases, indicating that this method demonstrates good performance as a testing method.

Objective: There are no reports from Japan showing the effects of using the thromboelastography algorithm on transfusion requirements after Intensive Care Unit (ICU) admission, and post-implementation knowledge regarding the thromboelastography algorithm under the Japanese healthcare system is insufficient. Therefore, this study aimed to clarify the effect of the TEG6s thromboelastography algorithm on transfusion requirements for patients in the ICU after cardiac surgery., Methods: We retrospectively compared the requirements for blood transfusion up to 24 h after ICU admission using the thromboelastography algorithm (January 2021 to April 2022) (thromboelastography group; n = 201) and specialist consultation with surgeons and anesthesiologists (January 2018 to December 2020) (non-thromboelastography group; n = 494)., Results: There were no significant between-group differences in terms of age, height, weight, body mass index, operative procedure, duration of surgery or cardiopulmonary bypass, body temperature, or urine volume during surgical intervention. Moreover, there was no significant between-group difference in the amount of drainage at 24 h after ICU admission. However, crystalloid and urine volumes were significantly higher in the thromboelastography group than in the non-thromboelastography group. Additionally, fresh-frozen plasma (FFP) transfusion volumes were significantly lower in the thromboelastography group. However, there were no significant between-group differences in red blood cell count or platelet transfusion volume. After variable adjustment, the amount of FFP used from the operating room to 24 h after ICU admission was significantly reduced in the thromboelastography group., Conclusions: The thromboelastography algorithm optimized transfusion requirements at 24 h after admission to the ICU following cardiac surgery., (© 2023. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Objectives: Effects of aortopulmonary collaterals (APCs) on outcomes after the total cavopulmonary connection (TCPC) are unclear. This study evaluated the incidence of APCs before and after TCPC and analysed the impacts of APCs on adverse outcomes., Methods: A total of 585 patients, who underwent TCPC from 1994 to 2020 and whose preoperative angiographies were available, were included. Pre-TCPC angiograms in all patients were used for the detection of APCs, and post-TCPC angiograms were evaluated in selected patients. Late adverse events included late death, protein-losing enteropathy (PLE) and plastic bronchitis (PB)., Results: The median age at TCPC was 2.3 (1.8-3.4) years with a body weight of 12 (11-14) kg. APCs were found in 210 patients (36%) before TCPC and in 81 (14%) after TCPC. The closure of APCs was performed in 59 patients (10%) before TCPC, in 25 (4.2%) at TCPC and in 59 (10%) after TCPC. The occurrences of APCs before and after TCPC were not associated with short-term or mid-term mortality. The APCs before TCPC were associated with chylothorax (P = 0.025), prolonged chest tube duration (P = 0.021) and PB (P = 0.008). The APCs after TCPC were associated with PLE (P < 0.001) and PB (P < 0.001). With APCs following TCPC, freedom from PLE and PB was lower than without (P < 0.001, P < 0.001)., Conclusions: APCs before TCPC were associated with chylothorax, prolonged chest tube duration and PB. APCs after TCPC were associated with both PLE and PB. The presence of APCs might affect the lymph drainage system and increase the incidence of chylothorax, PLE and PB., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The use of bone wax (BW) is controversial for sternal haemostasis because it increases the risk of wound infection and inhibits bone healing. We developed new waxy bone haemostatic agents made from biodegradable polymers containing peptides and evaluated them using rabbit models., Methods: We designed 2 types of waxy bone haemostatic agents: peptide wax (PW) and non-peptide wax (NPW), which used poly(ε-caprolactone)-based biodegradable polymers with or without an osteogenesis-enhancing peptide, respectively. Rabbits were randomly divided into 4 groups based on treatment with BW, NPW, PW or no treatment. In a tibial defect model, the bleeding amount was measured and bone healing was evaluated by micro-computed tomography over 16 weeks. Bone healing in a median sternotomy model was assessed for 2 weeks using X-ray, micro-computed tomography, histological examination and flexural strength testing., Results: The textures of PW and NPW (n = 12 each) were similar to that of BW and achieved a comparable degree of haemostasis. The crevice area of the sternal fracture line in the BW group was significantly larger than that in other groups (n = 10 each). The PW group demonstrated the strongest sternal flexural strength (n = 10), with complete tibial healing at 16 weeks. No groups exhibited wound infection, including osteomyelitis., Conclusions: Waxy biodegradable haemostatic agents showed satisfactory results in haemostasis and bone healing in rabbit models and may be an effective alternative to BW., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Competing Interests: Nothing to declare.

Objective: Aortic surgery is often performed in elderly patients, and these patients have a high risk of postsurgical muscle weakness. To reinforce purposeful postsurgical rehabilitation, we aimed to investigate the factors associated with postsurgical muscle weakness in patients who underwent thoracic aortic surgery., Methods: This retrospective cohort study analyzed data of consecutive patients who underwent elective thoracic aortic surgery with cardiopulmonary bypass, and whose knee extensor isometric muscle strength (KEIS) were measured pre- and postoperatively at University Hospital between January 2012 and December 2018. The primary outcome was percent change in KEIS (% change in KEIS). Multivariate linear regression analysis was used to identify independent risk factors for % change in KEIS., Results: Overall, 218 patients were included. Multivariate linear regression analysis showed that mechanical ventilation time, days from initial sitting to 100 m walking, and the number of exercises in the rehabilitation room were associated with % change in KEIS., Conclusions: This study may serve as a reference to stratify patients at risk of postsurgical muscle weakness. The preventive or alternative interventions in patients undergoing thoracic aortic surgery will be assessed in future studies.

Competing Interests: Declaration of Competing Interest None.

During cardiopulmonary bypass, the major disturbances in coagulation systems were affected by perioperative hemo-dilutional changes. Dilutional coagulopathy which is usually followed by hemorrhage is often refractory at the end of cardiopulmonary bypass. Thus, perioperative monitoring of coagulation markers might be necessary to estimate the differential diagnosis of hemorrhage and decrease thrombotic complications. It is very important to understand the timely coagulation and hemolysis pattern after the weaning of cardiopulmonary bypass. There is a limitation of central laboratory test to get a real time perioperative hemostatic management. Point-of-care devices are increasingly applied in clinical practice as we used in our practice. The data from these devices are useful to establish optimal hemostatic strategies.

An aortic aneurysm (AA) is defined as focal aortic dilation that occurs mainly with older age and with chronic inflammation associated with atherosclerosis. The aneurysmal wall is a complex inflammatory environment characterized by endothelial dysfunction, macrophage activation, vascular smooth muscle cell (VSMC) apoptosis, and the production of proinflammatory molecules and matrix metalloproteases (MMPs) secreted by infiltrated inflammatory cells such as macrophages, T and B cells, dendritic cells, neutrophils, mast cells, and natural killer cells. To date, a considerable number of studies have been conducted on stem cell research, and growing evidence indicates that inflammation and tissue repair can be controlled through the functions of stem/progenitor cells. This review summarizes current cell-based therapies for AA, involving mesenchymal stem cells, VSMCs, multilineage-differentiating stress-enduring cells, and anti-inflammatory M2 macrophages. These cells produce beneficial outcomes in AA treatment by modulating the inflammatory environment, including decreasing the activity of proinflammatory molecules and MMPs, increasing anti-inflammatory molecules, modulating VSMC phenotypes, and preserving elastin. This article also describes detailed studies on pathophysiological mechanisms and the current progress of clinical trials., (© 2023. Japanese Society of Inflammation and Regeneration.)

At our hospital, we are conducting the "Clinical Study of a Patient-Specific Cardiac Support Net for Dilated Cardiomyopathy (jRCTs042180025)", a multi-facility clinical study of a customized cardiac support net (CSN). Here, we describe the cardiac rehabilitation (CR) of a heart failure (HF) patient after CSN treatment. The patient was a 65-year-old man who exhibited dilated cardiomyopathy (DCM) because of left ventricular non-compaction; his New York Heart Association status was class III. In November 2019, he received CSN treatment. The early CR program was adapted for this patient, and his postoperative course was uneventful. Functional measurements showed improved leg-muscle strength (before treatment: 61.4% BW; at discharge: 77.3% BW). During long-term follow-up, the patient's exercise tolerance increased, as shown by 6-minute walk distance (before treatment: 576 m; long-term follow-up: 600 m) and peak oxygen uptake (before treatment: 12.5 mL/kg/min; long-term follow-up: 13.3 mL/kg/min). In the 2 years since discharge, the patient has not been hospitalized for HF. This report is the first to show that the CSN can be used to perform a CR program in a DCM patient without significant functional decline., Competing Interests: Dr Toshiaki Akita is employed by iCorNet Co, a venture company of Nagoya University. The other authors have no conflicts of interest to declare.

Transcatheter aortic valve replacement (TAVR) for bicuspid aortic valve stenosis is challenging, and the absence of established methods for sizing the bicuspid aortic valve (BAV) complicates TAVR. We report a case of successful TAVR for bicuspid aortic stenosis with a severely calcified raphe. We used an undersized SAPIEN 3 valve, with three safety measures based on assessment of structural characteristics, sizing by the circle method, and deployment of the valve by the pressure-regulated method., Competing Interests: Declaration of competing interest Toyoaki Murohara received lecture fees from Bayer Pharmaceutical Co LTD, Daiichi Sankyo Co Ltd., Dainippon Sumitomo Pharma Co Ltd., Kowa Co Ltd., MSD, Mitsubishi Tanabe Pharma Corp, Nippon Boehringer Ingelheim Co Ltd., Novartis Pharma Kabushiki Kaisha, Pfizer Japan Inc., Sanofi-aventis, Takeda Pharmaceutical Co Ltd. Toyoaki Murohara received unrestricted research grants from Daiichi Sankyo Co Ltd., Dainippon Sumitomo Pharma Co Ltd., Kowa Co Ltd., MSD, Mitsubishi Tanabe Pharma Corp, Nippon Boehringer Ingelheim Co Ltd., Novartis Pharma Kabushiki Kaisha, Pfizer Japan Inc., Sanofi-aventis, Takeda Pharmaceutical Co Ltd., Astellas Pharma Inc., Otsuka Pharmaceutical Co Ltd., Teijin Pharma Ltd. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Arterial stiffness indices are used to assess the material properties of the arterial wall and are associated with cardiovascular events. Aortic stenosis (AS) is commonly caused by degenerative calcification and can be associated with increased arterial stiffness. However, the clinical implications of arterial stiffness indices in AS patients before and after treatment are unknown., Methods: This single-center observational study enrolled 150 consecutive patients who underwent transcatheter aortic valve implantation (TAVI) for severe AS. The cardio-ankle vascular index (CAVI) was measured before and after TAVI. The patients were divided into two groups according to the CAVI values before and after TAVI: high CAVI group and low CAVI group. Patient and echocardiographic data and clinical outcomes, including cardiac death and hospitalization for heart failure (HF), were compared., Results: The pre- and postprocedural CAVI was 7.90 (6.75-9.30) and 9.65 (8.90-10.65), respectively. In the analyses with preprocedural CAVI, preprocedural echocardiographic aortic valve peak flow velocity was significantly lower in the high CAVI group. No significant differences between the two groups were observed in the occurrence of cardiac death or hospitalization for HF. In the analyses with postprocedural CAVI, B-type natriuretic peptide levels and E / e ' ratio after TAVI were significantly higher in the high CAVI group. The composite of cardiac death and hospitalization occurrence for HF was significantly higher in the high CAVI group., Conclusion: CAVI before TAVI is mainly affected by the AS severity, while CAVI after TAVI is associated with left ventricular diastolic dysfunction and late cardiac events, which may reflect arterial stiffness., (Copyright © 2023 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background: This study was designed to investigate the incidence and types of pancreatic injury, risk factors, and time-course changes in computed tomographic findings following total aortic arch replacement with moderate hypothermic circulatory arrest., Methods: Medical records of patients who underwent total arch replacement between January 2006 and August 2021 were retrospectively reviewed. A comparison study between the patients with (group P) and without pancreatic injury (group N) was conducted to elucidate the impact of pancreatic injury. Follow-up computed tomography of the patients in group P was reviewed to investigate time-course changes of the pancreatic injury., Results: Of 353 patients, 14 (4.0%) had subclinical pancreatic injury. Computed tomographic findings were consistent with acute pancreatitis in all patients, of whom eight patients had interstitial edematous pancreatitis, whereas six patients had necrotizing pancreatitis. Although walled-off necrosis occurred in three patients, none of them required drainage. In-hospital mortality was 7.1% and 4.4% in groups P and N, respectively ( p   =  0.98). The 5-year actuarial survival rates were 77.9% and 81.0% in groups P and N, respectively ( p   =  0.51). Multivariate analysis revealed that pancreatic injury was associated with chronic obstructive pulmonary disease ( p   =  0.03)., Conclusions: This study highlighted that silent pancreatic injury after aortic arch surgery is underrecognized. Potential arterial sclerosis of the pancreatic circulation seems to be related to pancreatic injury.

Impella 5.0 circulatory support via subclavian artery (SA) access may be a safe approach for patients undergoing cardiac rehabilitation (CR). In this case series, we retrospectively analyzed the demographic characteristics, physical function, and CR data of six patients who underwent Impella 5.0 implantation via the SA prior to left ventricular assist device (LVAD) implantation between October 2013 and June 2021. The median age was 48 years, and one patient was female. Grip strength was maintained or increased in all patients before LVAD implantation (pre-LVAD) compared to after Impella 5.0 implantation. The pre-LVAD knee extension isometric strength (KEIS) was less than 0.46 kgf/kg in two patients and more than 0.46 kgf/kg in three patients (unavailable KEIS data, n = 1). With Impella 5.0 implantation, two patients could ambulate, one could stand, two could sit on the edge of the bed, and one remained in bed. One patient lost consciousness during CR due to decreased Impella flow. There were no other serious adverse events. Impella 5.0 implantation via the SA allows mobilization, including ambulation, prior to LVAD implantation, and CR can be performed relatively safely.

The Impella 5.0 is an axial-flow percutaneous ventricular assist device used in patients with cardiogenic shock. Although the recommended period of use is 10 days or less, weaning can be delayed because of ongoing hemodynamic instability. In clinical practice, this device sometimes malfunctions during long-term management with heparin and must be replaced; however, the relationship between the duration of support with the initial and replacement Impella 5.0 and the changes in value of the purge system has not been fully elucidated. From July 2018 to May 2021, Impella 5.0 was implanted and used for more than 10 days in 11 patients at our institution. Four patients required Impella replacement because of device malfunction and the second Impella had purge system malfunction in all cases. The second Impella was used for a significantly shorter time than the first Impella (p = 0016). We calculated the ratio of purge pressure to purge flow rate and found that the ratio exceeded 50 mm Hg/mL/h in all cases with purge system malfunction. In conclusion, it is important to construct a treatment strategy considering the duration of use, because the risk of purge system malfunction is high after replaced Impella 5.0., (© 2022. The Japanese Society for Artificial Organs.)

A 47-year-old man with dilated-phase hypertrophic cardiomyopathy was admitted to the hospital with worsening heart failure. As the enlarged atrium caused a constrictive pericarditis-like hemodynamic condition, atrial wall resection and tricuspid valvuloplasty were performed. Postoperatively, pulmonary artery pressure rose due to increased preload; however, the rise in pulmonary artery wedge pressure was restrained, and the cardiac output significantly improved. When the pericardium is extremely stretched due to atrial enlargement, it can lead to an elevation of intrapericardial pressure, and both atrial volume reduction and tricuspid valve plasty could lead to increased compliance and contribute to hemodynamic improvement., Learning Objective: Atrial wall resection for massive atrial enlargement and tricuspid annuloplasty in patients with diastolic-phase hypertrophic cardiomyopathy effectively relieves unstable hemodynamics., Competing Interests: The authors have no relevant disclosures in this article., (© 2023 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: We evaluated the impact of a standardized driveline care strategy, including a subfascial-tunneling method and dressing protocol, on the incidence of driveline infection (DLI)., Methods: DLI data from all HeartMate II (HMII) and HeartMate 3 (HM3) patients (including exchange devices) were retrospectively collected between 2013 and 2021. The driveline subfascial-tunneling method was altered in three steps (A: right direct; B: left triple, C: right triple), and the shower protocol was changed in two steps (A: with/without cover, B: with cover). Disinfection was individually tailored after changing the shower protocol. Complications associated with morbidity and mortality were evaluated for each modification., Results: During the study period, 80 devices were implanted (HMII, n = 54; HM3, n = 26). The 8-year incidence of DLI was 15% (n = 8) in HMII patients and 0% in HM3 patients (p = 0.039). DLI was not associated with hospital mortality. The modified dressing protocol and tunneling method was associated with a significantly better DLI incidence rate in comparison to the previous one: Protocol-A (n = 17), Protocol-B (n = 63), 35% vs 3% (p = 0.0009), Method-A (n = 13), Method-B (n = 42), Method-C (n = 25), 46% vs 5% vs 0% (p = 0.0001). The rete of freedom form DLI at 1, 2, and 3 years had also significant difference between groups: Protocol-A and Protocol-B, 80%, 54%, 54% vs 96%, 96%, 96%, respectively (p < 0.0001), Method-A, Method-B and Method-C, 76%, 44%, 44%, vs 94%, 94%, 94% vs 100%, 100%, respectively (p < 0.0001)., Conclusions: A standardized triple driveline tunneling strategy and waterproof dressing protocol reduced driveline infection in HM3 patients to 0%., (© 2022 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: The effect of delayed ambulation on the outcome of coronary artery bypass grafting (CABG) remains to be clarified., Methods and results: The long-term and in-hospital outcomes of 887 patients who underwent isolated CABG (455 off-pump cases, 135 urgent cases) were evaluated, with a focus on the timing of first ambulation. In-hospital mortality cases were excluded. Early ambulation (first ambulation within 3 days after operation) was achieved in 339 (38%) patients. In the multivariable logistic regression analysis, longer operation time and urgent case, EuroSCORE II, re-thoracotomy, and respiratory time were associated with delayed (≥4 days) ambulation. Delayed ambulation was associated with a high incidence of postoperative complications, such as pneumonia, and stroke (P<0.01). Following discharge, 22.2% of patients experienced major cardiac events and 13.8% died during the follow-up period (median follow-up 60 months). Cox hazards analysis revealed that delayed ambulation was associated with long-term adverse events (hazard ratio 1.04 per day, P<0.001). With adjustment for preoperative factors, the estimated future risk of adverse events was found to be increased day-by-day during the delay until initial ambulation., Conclusions: In isolated CABG patients, delayed ambulation was associated with poor outcomes, even in the long-term period. The results support the current guideline recommending early ambulation protocol after cardiac surgery.

Aortic aneurysm (AA) is a vascular disorder characterized pathologically by inflammatory cell invasion and extracellular matrix (ECM) degradation. It is known that regulation of the balance between pro-inflammatory M1 macrophages (M1Ms) and anti-inflammatory M2 macrophages (M2Ms) plays a pivotal role in AA stabilization. We investigated the effects of M2M administration in an apolipoprotein E-deficient (apoE -/- ) mouse model in which AA was induced by angiotensin II (ATII) infusion. Mice received intraperitoneal administration of 1 million M2Ms 4 weeks after ATII infusion. Compared with a control group that was administered saline, the M2M group exhibited reduced AA expansion; decreased expression levels of interleukin (IL)-1β, IL-6, tumor necrosis factor-α (TNF-α), and monocyte chemoattractant protein-1 (MCP-1); and a lower M1M/M2M ratio. Moreover, the M2M group exhibited upregulation of anti-inflammatory factors, including IL-4 and IL-10. PKH26-labeled M2Ms accounted for 6.5% of cells in the aneurysmal site and co-expressed CD206. Taken together, intraperitoneal administration of M2Ms inhibited AA expansion by reducing the inflammatory reaction via regulating the M1M/M2M ratio. This study shows that M2M administration might be useful for the treatment of AA., (© 2023. The Author(s).)

A validation study was performed on the modified analytical method for the migration solution of heptane, 20% ethanol and 4% acetic acid for the determination of bisphenol A migrating from polycarbonate food apparatuses, containers, and packaging. The analytes for the method were bisphenol A, phenol and p-tert-butylphenol. The repeatability, within-laboratory reproducibility and trueness of the method was estimated in the range of 0.2-1.8%, 0.4-2.6% and 95-102% respectively. These results showed that the method is useful as an analytical method for the migration solution of heptane, 20% ethanol and 4% acetic acid. Furthermore, the applicability of the determination methods with a fluorescence detector was verified. As a result of the validation study, the repeatability, within-laboratory reproducibility and trueness of the method was estimated in the range of 0.1-2.9%, 0.2-3.1% and 94-101% respectively. It was confirmed that the measurement with a fluorescence detector is also available.

Migrants found in migration solutions obtained from commercially available polyethylene products that may contain food were studied and analysed via liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (LC-QTOF) for non-target screening and LC-MS/MS for quantifying 14 substances in migration solutions. Furthermore, an analytical approach based on the retention gap was developed for accurate separation techniques using LC-MS/MS. Irganox 1076 was detected at a maximum of 1.5 mg/kg, which was 1/4 of the Specific Migration Limit in the EU, in nine commercially available plastic bags tested. This is in accordance with European Regulation No 10/2011/EU. Furthermore, migration of Erucamide and Irgafos 168-oxide was confirmed.