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Background Left ventricle aneurysm (LVA) as a sequela to myocardial infarction or iatrogenic injury is required surgical treatment with full median sternotomy. Herein, we report a case of successful surgical treatment of left ventricle aneurysm performed by minimally invasive cardiac surgery (MICS). Case presentation We describe a case of a LVA treated by minimally invasive cardiac surgery in an 82-year-old woman who reported to the hospital with the complaint of chest pains at rest. Computed tomography (CT) coronary angiography revealed a left ventricle apical aneurysm. The aneurysm was suspected to be a pseudoaneurysm caused by a previous myocardial infarction. Surgery was performed under general anesthesia, with the patient in a supine position. A small incision was made in the 3rd intercostal space through which an aortic root vent cannula and aortic clamp were inserted, followed by exposing the aneurysm via incision of the left 6th intercostal space. The aneurysm was resected and pathologically examined, revealing it to be a “true” aneurysm. The left ventricle wall was closed using polypropene mattress sutures. Postoperative CT scan revealed successful resection of the aneurysm. Usually, a surgical treatment with full median sternotomy and left ventriculostomy is indicated for LVA. We decided to treat the LVA with bilateral thoracotomy MICS. We preferred to perform this procedure under cardiac arrest to ensure safe and secure closure of the aneurysm. The right small thoracotomy was necessary for aortic cross-clamping and aortic root venting. Conclusions The procedure was safe and simple and yielded excellent postoperative outcomes. Therefore, we speculate that this method can be applied to the management of larger aneurysms.

Post-myocardial infarction ventricular septal rupture (PIVSR) is becoming increasingly rare in the percutaneous coronary intervention era; however, the mortality rates remain high. Surgical repair is the gold standard treatment for PIVSR but is associated with surgical difficulty and high mortality. Therefore, the timing of surgery is controversial (i.e. either undertake emergency surgery or wait for resolution of organ failure and scarring of the infarcted area). Although long-term medical management is usually ineffective, several mechanical circulatory support (MCS) devices have been used to postpone surgery to an optimal timing. Recently, in addition to venous arterial extracorporeal membrane oxygenation (VA-ECMO), new MCS devices, such as Impella (Abiomed Inc., Boston, MA, USA), have been developed. Impella is a pump catheter that pumps blood directly from the left ventricle, in a progressive fashion, into the ascending aorta. VA-ECMO is a temporary MCS system that provides complete and rapid cardiopulmonary support, with concurrent hemodynamic support and gas exchange. When left and right heart failure and/or respiratory failure occur in cardiogenic shock or PIVSR after acute myocardial infarction, ECpella (Impella and VA-ECMO) is often introduced, as it can provide circulatory and respiratory assistance in a shorter period. This review outlines the basic concepts of MCS in PIVSR treatment strategies and its role as a bridge device, and discusses the efficacy and complications of ECpella therapy and the timing of surgery.

Infective endocarditis is an infection of the endocardium that can cause major complications. While surgery may reduce complications and improve survival, the surgery is of high risk and has a high mortality rate. Indications for early surgical treatment include advanced heart failure, refractory infection, and embolism. The most prominent form of heart failure associated with infective endocarditis is valve regurgitation owing to valve destruction caused by the infection. If the infection is not resolved after 3-5 days of antimicrobial therapy, the diagnosis of refractory infection should be made, and early surgical intervention should be performed. The most frequent embolism is of the central nervous system. Guidelines in Japan state that surgery should not be postponed in the case of cerebral infarction and recommend waiting four weeks for open heart surgery in the case of new intracranial hemorrhage. In addition, the presence of infected cerebral aneurysms should not be overlooked during early surgical intervention. Infected cerebral aneurysms are diagnosed using computed tomography angiography or magnetic resonance angiography. Finally, it is important to consider the timing of surgery based on day-to-day changes in the patient's condition, including onset of heart failure, infection status, and vegetation expansion.

Background This study compared the clinical outcomes of transcatheter (TAVR) and surgical (SAVR) aortic valve replacements, focusing on postoperative valvular performance assessed by echocardiography. Method and Results A total of 425 patients who underwent TAVR (230 patients) or SAVR (195 patients) were included. Postoperative effective orifice area index (EOAI) was higher in the TAVR group (1.27 ± 0.35 cm2/m2) than in the SAVR group (1.06 ± 0.27 cm2/m2, p < 0.001), and patient–prosthesis mismatch (PPM) was more frequent in the SAVR group (22.6%) than in the TAVR group (8.7%, p < 0.001). Mild or greater paravalvular leakage (PVL) was more frequent in the TAVR group (21.3%) than in the SAVR group (0%, p < 0.001). Moreover, there was no difference in freedom from all-cause death, stroke, or rehospitalization between the groups. Patients with moderate or greater PPM (EOAI < 0.85 cm2/m2) had lower freedom from composite events than those without this PPM criterion (p = 0.008). Patients with mild or greater PVL also had lower freedom from composite events than those without this PVL criterion (p = 0.017). Conclusions Postoperative valvular performance of TAVR was superior to that of SAVR in terms of EOAI. This merit was counterbalanced by the significantly lower rates of PVL in patients who underwent SAVR. The overall clinical outcomes were similar between the study groups.

The Jarvik 2000, with a postauricular cable, is a left ventricular assistance device with a driveline that is passed to the postauricular region subcutaneously. A titanium pedestal base that holds a 3-pin connector is fixed to the parietal bone, posterior to the auricle. Essentially, the device is fixed in the same position as a cochlear implant; however, the disadvantages include continuous mechanical stress on the cable by neck rotations, and the visibility of the apparatus. To improve such concerns, we adjusted the location of the pedestal of the lower parietal bone to just above the transverse sinus and closer to the mastoid process. To reach this point, the internal cable was passed through the retromastoid pathway commonly used in ventriculoperitoneal shunting. The thickness of the skull at this location is sufficient for safe fixation; however, preoperative evaluation by a neurosurgeon using CT is necessary.

OBJECTIVES In patients with cardiogenic shock, delayed surgery after stabilization of haemodynamics and improvement in end-organ function by mechanical circulatory support is known to yield better outcomes than emergency surgery. We aimed to investigate the effectiveness of Impella (Abiomed, Danvers, MA, USA) as a bridge to cardiac surgery in patients with cardiogenic shock. METHODS We reviewed 7 patients with cardiogenic shock who underwent Impella support as a bridge to cardiac surgery using cardiopulmonary bypass at our institution between April 2018 and August 2021. RESULTS Cardiogenic shock was caused by ventricular septal rupture in 3 patients, papillary muscle rupture in 1 and acute myocardial infarction in 3. Cardiac surgery was delayed by 1–7 (3.9 ± 2.5) days with Impella support after the diagnosis of cardiogenic shock, during which the hepatic and renal function of the patients improved significantly. Device-related or operation-related adverse events included re-exploration for bleeding in 3 patients, acute limb ischaemia due to thromboembolism in 1 and intraoperative aortic dissection in 1. Thirty-day mortality was 14.3%, and the cumulative survival was 71.4% at 1 year. The survival tended to be better than that in historical control group in which extracorporeal membrane oxygenation was used as a bridge to surgery (P = 0.0992). CONCLUSIONS Impella is an effective tool for bridging patients with cardiogenic shock to surgery. This strategy may improve surgical outcomes in patients with cardiogenic shock. However, prolonged Impella support may increase significant adverse events, and further investigation is required to determine the optimal duration of support before surgery.

Sarcopenia is closely associated with postoperative prognosis in patients undergoing cardiovascular surgery. Growth differentiation factor (GDF)-15 is involved in the pathogenesis of cardiovascular disease. We examined the relationship between the serum GDF-15 concentration and muscle function in patients receiving aortic valve replacement and healthy elderly subjects.Forty-three female patients undergoing aortic valve surgery (79.9 ± 6.4 years; transcatheter aortic valve replacement [TAVR] n = 19, conventional surgical aortic valve replacement [SAVR] n = 24) and 64 healthy elderly female subjects (75.9 ± 6.1 years) were included. Walking speed, grip strength, and skeletal muscle mass index (SMI) by a multifrequency bioelectrical impedance analyzer were measured to determine the presence of sarcopenia. Preoperative serum GDF-15 concentration was measured by enzyme-linked immunosorbent assay.The GDF-15 level was higher in patients receiving aortic valve replacement than in healthy elderly subjects (aortic valve replacement: 1624 ± 1186 pg/mL vs. healthy: 955 ± 368 pg/mL, p 0.001). Multivariate linear regression analysis showed that the serum GDF-15 level determined grip strength independently of the high-sensitivity C-reactive protein level and eGFR, even after adjusting for age (β = -0.318, p = 0.025). Sarcopenia was found in 12.5% of healthy elderly subjects, 83.3% of patients with TAVR, and 64.3% of patients with SAVR. The GDF-15 concentration that defined sarcopenia was 1109 pg/mL in subjects including patients receiving aortic valve replacement.The preoperative serum GDF-15 concentration, which was higher in female patients receiving aortic valve replacement than in healthy elderly subjects, may be a serum marker of sarcopenia.

Cardiovascular surgery in older patients with sarcopenia has high rates of major complications, long hospital stays, readmissions, and discharge transfers. However, the factors that influence the length of hospital stay are unknown. This study aimed was to identify the predictors of the prolonged hospital stay in patients with sarcopenia after cardiovascular surgery.A total of 192 patients scheduled for cardiac surgery were enrolled in this retrospective observational study. Sarcopenia was diagnosed preoperatively. Clinical data from the preoperative, intraoperative, and perioperative periods were evaluated to determine the factors influencing the length of hospital stay.The sarcopenia and non-sarcopenia groups differed significantly in age; body mass index; renal function; intubation time; transfusion of red blood cells; hospital transfer; and hemoglobin, brain natriuretic peptide, and albumin levels. Sarcopenia was the most significant factor influencing prolonged postoperative hospital stay, as well as prolonged intubation time. In the sarcopenia group, albumin levels and cardiopulmonary bypass time were the significant factors affecting hospital stay.Sarcopenia was the most significant factor associated with prolonged postoperative hospital stay in patients who underwent cardiac surgery. In addition, improving sarcopenia, nutritional status, and shortening cardiopulmonary bypass time appear to shorten the hospital stay in patients with sarcopenia who underwent cardiovascular surgery.

Limited studies have assessed the factors affecting prognosis in hemodialysis (HD) patients who undergo surgical aortic valve replacement with a bioprostheses (SAVR-BP). This study aimed to evaluate the outcomes of HD patients who had undergone SAVR-BP for aortic stenosis (AS) and identify the risk factors for mortality.This retrospective study included 57 HD patients who had undergone SAVR-BP for AS between July 2009 and December 2020. Multivariate logistic regression was used to predict factors associated with mid-term outcomes and death or survival. Kaplan - Meier curves were also generated for mid-term survival.The in-hospital mortality rate was 8.8%, and the 5-year mortality rate was 42.1%. The independent predictors of 5-year mortality were preoperative age (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.175-2.083, p = 0.002), hyperlipidemia (HR, 0.02; 95% CI, 0.002-0.297, p = 0.004), left ventricular diastolic diameter (HR, 1.74; 95% CI, 1.142-2.649, p = 0.010), left ventricular systolic diameter (HR, 0.61; 95% CI, 0.392-0.939, p = 0.025), and Japan SCORE (HR, 1.28; 95% CI, 1.052-1.563, p = 0.014). The postoperative predictors included intensive care unit stay (HR, 1.11; 95% CI, 1.035-1.194, p = 0.004) and albumin level (HR, 0.38; 95% CI, 0.196-0.725, p = 0.003).The 5-year prognosis of HD patients undergoing SAVR may be improved by early diagnosis (before the occurrence of LV hypertrophy/enlargement) and nutritional management with oral intake to alleviate postoperative hypoalbuminemia.

Introduction: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. Hypothesis: To investigate the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. Methods: Total 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by Enzyme-Linked Immunosorbent Assay. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. Results: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels; perioperative data (urine output); ICU stay period; and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. The risk of developing AKI increased with increasing preoperative ET-1 level at baseline (OR for 1 pg/mL increase in ET-1, 2.177; 95% CI, 1.034-4.584; p = 0.041) and CPB time (OR for 1 h increase in CPB time, 4.194; 95% CI, 2.005-8.773; p < 0.001), even adjusted by age, sex, and BMI. In addition, multivariable logistic regression analysis showed that the risk of 30-day mortality plus morbidity increased with increasing preoperative GDF-15 level at baseline, CPB time, and RCC transfusion, even adjusted for age, gender, and BMI. Conclusion: The present study provides evidence that preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risk for patients undergoing cardiovascular surgery.

Introduction: Atrial fibrosis plays an important role in atrial remodeling and the development of atrial fibrillation (AF). Left atrium (LA) strain (LAS) measured by two-dimensional speckle tracking echocardiography (2DS) has been reported to be a useful method to predict the degree of atrial fibrosis. Hypothesis: To investigate whether LAS is an early marker of atrial fibrosis in cardiovascular surgery patients. Methods: Conventional echocardiography and 2DS method were performed in 131 patients (53 AF, 78 sinus rhythm (SR)) including cardiac valve disease (MR, AS, and CABG et al.). The mRNA and microRNA expression were analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) in 59 cases in which LA tissues were removed from the appendage. Results: Left atrial reservoir strain (LASr) negatively correlated with left atrial volume index (LAVI), and E/e’ and positively correlated with LVEF, and left atrial conduit strain (LAScd). LASr was significantly lower, and LAVI was higher in AF group. The fibrosis-related (COL1A, COL3A1, TGFβ1) and peroxisome proliferator-activated receptor-α (PPARα)-related (PPARα, PGC1α, CPT1B) genes expression as a metabolic remodeling showed a positive association with atrial ANP mRNA expression level, reflecting atrial pressure and mechanical stretching. The expression level of COL1A and TGFβ1 mRNA was higher in AF group, compared with SR group. LASr, but not LAVI, negatively correlated with the expression of COL1A1, TGFβ1, and miR21. Multivariate regression analysis showed that LASr was an independent predictor of COL1A1, TGFβ1, or miR21 expression. The PPARα-related gene expression did not correlate with LASr, and LVEF in SR group, while they had a significant negative correlation with LVEF in AF patients. AF patients (LVEF Conclusions: Low LASr exhibits increased atrial fibrosis, and LASr is extremely useful as an early marker for predicting atrial fibrosis and consequently AF in cardiovascular surgery patients. Furthermore, in progressed AF patients, overexpression of PPARα signaling may play a role in atrial degeneration eventually to leading to heart failure.

A 76-year-old woman with unstable angina underwent coronary stent implantation. At the same time, rosuvastatin therapy was started. However, she experienced repeated in-stent restenosis (ISR). Treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor along with rosuvastatin (5 mg/day) reduced plasma low-density lipoprotein cholesterol to 10 mg/dL, but failed to prevent further ISR. Eventually, an increase in the rosuvastatin dose to the permitted maximum of 20 mg/day succeeded in preventing further in-stent restenosis. Rather than using PCSK9 inhibitors, intensive statin treatment, using the maximum dose of statins, should be prioritized for the secondary prevention of coronary artery disease.

The maximum limit on overtime working hours for physicians will be applied from 2024. To explore sociodemographic and work-related factors influencing overtime work among cardiovascular surgeons (CS) in Japan. This cross-sectional study included 607 CS who responded to an online survey. Working hours were categorized into ≤60 hours, 60-79 hours, and ≥80 hours per week according to Japan Ministry of Health, Labour and Welfare. Adjusted odds ratios (aOR) were calculated using a multinomial analysis with stepwise reduction after adjustment for potential confounders. Compared to ≤60 hours, significant factors related to 60-79 hours and ≥80 hours per week were age groups of 30s to 50s versus 60s (aOR: 7.48-3.22 and 23.64-4.87), management with cardiovascular drugs (aOR: 1.87 and 5.80), and postoperative wound management (aOR: 0.47 and 0.16), respectively. Significantly related informed consent for surgery (aOR: 3.29) was seen in 60-79 hours. Contrarily, CS who worked for ≥80 hours took on-duty 5 times or more per month (aOR: 3.89), performed night or holiday calls 20 times or more per month (aOR: 2.26), and attended the intensive care unit (aOR: 3.12). These findings suggest that younger, and some non-surgical work-related factors could influence long working hours among CS.

A 58-year-old man with Marfan syndrome visited our clinic for a routine examination. He had undergone a modified Bentall procedure with Carrel patch technique for annuloaortic ectasia 15 years previously. Computed tomography revealed an aneurysm of 43×57 mm in diameter at the right coronary ostium. He underwent resection of the aneurysm and coronary reconstruction using Piehler technique. He was discharged on the 37th postoperative day when his renal function recovered. Although the modified Bentall procedure may improve the surgical outcome, long-term follow-up is important because of various postoperative anastomotic complications in patients with Marfan syndrome.

Objectives This study aimed to compare the short-term outcomes of transcatheter and surgical aortic valve replacements (TAVR and SAVR) in high-, intermediate-, and low-preoperative risk patients. Methods A total of 454 patients who underwent TAVR or SAVR were included. Patients were categorized into high-, intermediate-, and low-risk according to the Society of Thoracic Surgery-Predicted Risk of Mortality score and clinical outcomes were compared between TAVR and SAVR groups. Results TAVR was less invasive, with less bleeding and transfusion (p p p p = 0.003) and pressure gradient (p p p p Conclusions TAVR was superior to SAVR in the sense of less invasiveness and valvular function. However, the indication of TAVR in low-risk patients should be carefully discussed, because paravalvular leakage was a risk factor for short-term mortality.

Dipeptidyl peptidase 4 (DPP-4) is a novel adipokine and may be involved in the association between adipose tissue and metabolic syndrome. We investigated DPP-4 and adiponectin levels in the serum, subcutaneous adipose tissue (SAT), and epicardial adipose tissue (EAT), and their relationship with preoperative factors, as well as comparing the DPP-4 levels in SAT and EAT with and without DPP-4 inhibitors. This study included 40 patients (25 men, age 67.5 ± 13.8 years). The serum adipokine, DPP-4, and adiponectin levels in SAT and EAT were measured using ELISA and Western blotting. The DPP-4 and adiponectin levels were significantly higher in the SAT than in the EAT. The serum DPP-4 and DPP-4 activity levels had no correlation with the DPP-4 levels in the SAT and EAT, but the DPP-4 levels in the SAT and EAT had a positive correlation. The DPP-4 levels in the SAT were positively correlated with atherosclerosis, diabetes mellitus, DPP-4-inhibitor use, and fasting blood glucose. The DPP-4 levels in the EAT showed a negative correlation with eGFR and a positive correlation with atrial fibrillation. The DPP-4 activity in the serum had a lower tendency in the group taking DPP-4 inhibitors than in the group not taking them. DPP-4 inhibitors may suppress angiogenesis and adipose-tissue hypertrophy.

Hemolytic anemia is a rare postoperative complication of aortic surgery, which may be caused by an excessively kinked graft that causes abnormal blood flow. It has been reported that 4-dimensional flow magnetic resonance imaging (4D flow MRI) can identify abnormal flow. Herein, we report the guidance of 4D flow MRI in performing the revision procedure for a patient with hemolytic anemia by evaluating abnormal blood flow based on this method.A 70-year-old woman presented with dizziness and fatigue. She had undergone total arch replacement with a frozen elephant trunk 5 years prior. We diagnosed hemolytic anemia caused by a kinked graft after total arch replacement.Although computed tomography findings revealed 3 lesions of the kinked graft at the ascending portion and cervical branches, 4D flow MRI findings showed that only the kinked graft at the ascending portion caused hemolytic anemia due to an elevated viscous energy loss around it.We performed surgery to remove the kinked section instead of revision surgery consisting of total arch replacement.The patient's postoperative course was uneventful and there were no complications. Postoperative enhanced computed tomography findings showed that the repaired graft had an adequate length and smoothly curved shape. The 4D flow MRI findings revealed smooth flow in the ascending portion and decreased viscous energy loss.Based on the 4D flow MRI findings, we adopted a less invasive approach, repairing only the ascending portion of the graft, instead of performing revision surgery comprising total arch replacement.

Coronary sinus aneurysm is a rare heart anomaly. Herein, we report a rare case with giant coronary sinus aneurysm misdiagnosed as an extracardiac mediastinal tumor. The preoperative diagnostic imaging failed to diagnose the correct location of the tumor and a simple resection was planned. It turned out to be coronary sinus aneurysm intraoperatively and required cardiopulmonary bypass support for the resection.

Introduction: Surgery for cardiovascular disease is often accompanied by sarcopenia and physical frailty, and improvement of muscle mass, muscle strength, and ADL, is often difficult only with cardiac rehabilitation using aerobic exercise. The resistance training under moderately restricted muscle blood flow, named as KAATSU, induces muscle hypertrophy and strengthens muscle through low intensity exercise. However, it remains uninvestigated whether KAATSU resistance training using low intensity load (KAATSU-RE) increases muscle strength, and induces hypertrophy in patients early after cardiovascular surgery. Hypothesis: To investigate the effects of KAATSU-RE on skeletal muscle strength, hypertrophy and its safety in patients early after cardiovascular surgery. Methods: Nine patients early after cardiac surgery were included in this study (seven males, age 54 ± 18 years, BMI 23.0 ± 3.7 kg/m 2 , AVR 5 cases, MVP 3, Bentall operation 1). The patients performed leg extension exercise (20~30% 1RM) under KAATSU condition two times/week for three months. Training started after 200 m walking early after the operation. Skeletal muscle mass index (SMI) was evaluated using bioelectrical impedance analysis (BIA). The anterior mid-thigh thickness (MTH) was measured using B mode transverse ultrasound images. Physical functions (isometric knee extension peak torque, handgrip strength, and walking speed) were also measured at three points, i.e. baseline (before operation), ~7 days early after operation, and ~3 months after the training. Results: SMI and MTH decreased significantly from 7 ± 1.1, and 2.5 ± 0.4 cm preoperatively to 6.7 ± 1.0, and 2.2 ± 0.3 cm approximately 1 week after surgery. Approximately 3 months after the training, they increased significantly to 7.6 ± 0.8 and 3 ± 0.4 cm. During the rehabilitation period, hemodynamic deterioration and side effects including subcutaneous hemorrhage were not observed, and all the patients completely finished the study. Conclusions: These results suggest that KAATSU training safely increased muscle mass in patients in the early perioperative period of cardiovascular surgery. KAATSU training appears to be a promising and effective method for cardiac rehabilitation in patients with cardiovascular surgery.

Introduction: Atrial fibrosis plays an important role in atrial remodeling and the development of atrial fibrillation (AF). Transforming growth factor β1 (TGFβ1) is one of the major factors that accelerate atrial fibrosis. Left atrium global peak longitudinal strain (GPLS) measured by two-dimensional speckle tracking (2DS) method has been reported to be a useful method to predict the degree of atrial fibrosis. Hypothesis: To investigate the association between GPLS, Af and atrial fibrotic remodeling by analyzing fibrosis-relating gene expression including collagen type 1 (COL1A1), and TGFβ1 in cardiovascular surgery patients. Methods: Conventional echocardiography and 2DS method were performed in 117 patients (36 atrial fibrillation (Af) patients, 81 patients with sinus rhythm (SR), average age 69.7 years, 69 males) before cardiovascular surgery including cardiac valve replacement, and CABG. The fibrosis-relating gene expression such as collagen type 1 (COL1A1), COL4A1, TGFβ1, and connective tissue growth factor (CTGF) mRNA were analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) in 39 cases in which LA tissues were removed from the appendage during surgery. Results: GPLS was significantly negatively correlated with left atrial diameter (LAD), E/e‘, and left atrial volume index (LAVI). Expression of TGFβ1 in the atrium was positively correlated with expression level of Col1A1, Col4A1, and CTGF mRNA. GPLS was significantly negatively correlated with the expression of Col1A1 (r = -0.418, p = 0.015), TGFβ1 (r = -0.557, p = 0.000), and Col4A1 (r = -0.411, p = 0.013). However, no clear correlation was observed with LAD and LAVI. In multivariate analysis, unlike LAD and LAVI, GSLS was a clear predictor of Col1A1 expression, even when corrected with gender, age, brain natriuretic peptide (BNP), and type of heart rhythm (Af, sinus rhythm). On the other hand, TGFβ1 concentration in blood did not correlate with TGFβ1, Col1A1 and Col41A mRNA expression level in the atrium. Conclusions: Low LA GPLS exhibits increased atrial fibrosis reflected by collagen and TGFβ1 expression , irrespectively of heart rhythm (Af or sinus rhythm), and becomes an extremely useful marker for predicting LA fibrosis in cardiovascular surgery patients.

Introduction: In patients with heart failure, malnutrition is often associated with sarcopenia, and cachexia, closely related to the prognosis of the disease. Phase angle(PA) is an angle that expresses the resistance of the cell membrane, and is related to the health of the cell and the nutritional state of the cell membrane. It is attracting attention as a prognostic factor and nutritional index for various diseases. We investigated the clinical usefulness of PA as markers of sarcopenia, cachexia and malnutrition in hospitalized patients with cardiovascular disease. Methods: Total 412 patients(277 males and 135 females) who underwent cardiac rehabilitation on admission due to cardiovascular diseases were included in this study. We performed body composition analysis(Inbody S10) such as PA, and skeletal muscle mass index(SMI). The nutritional states were evaluated by BMI, CONUT score, blood albumin level(Alb), and Hb. The blood concentration of BNP and eGFR were also measured. Sarcopenia was judged by the AWGS algorithm, and cachexia was judged by using BMI Results: Both SMI and PA negatively correlated with age, and positively correlated with BMI, grip strength, knee extension strength, and SPPB score in both sexes. SMI and PA were also significantly associated with CONUT score, Hb, and Alb in males, but PA was more strongly associated with these nutritional aspects. In females, PA was correlated with Hb and Alb, but not with SMI. Sarcopenia was found in 31.6% of men and 32.4% of women. The cut-off values of PA obtained from the ROC curve in patients with sarcopenia were 4.55°for males and 4.25°for females. The cut-off values for PA in ROC curves for those with cachexia were 4.15°for males and 4.25°for females. When grip strength, knee extension strength, CRP, BNP, eGFR, Hb, and Alb were independent factors, multiple regression analysis showed that grip strength and BNP were the independent determinants of SMI, whereas grip strength, BNP, and Hb were the independent determinants of PA, after adjusting for age and BMI in males. Conclusions: This study provides the evidence showing that PA can be highly useful as a marker for sarcopenia, malnutrition and then cachexia in hospitalized patients with cardiovascular disease.

To identify the conflicts between a career as a surgeon and pregnancy and childbirth for women in Japan. The Japan Surgical Society conducted a nationwide survey on pregnancy and childbirth among its members who are women. The questionnaire included items regarding demography, working styles, and pregnancy and childbirth, including adverse events and harassment. The response rate was 29.9% (1068 responses, median age, 37 years). Among the responders, 61% were married and 47% had children (average number of children, 1.7). Half of the respondents reported having experienced sexual harassment and 62% reported having received unwelcome comments about pregnancy. About 20% had undergone fertility treatment. In total, 51% had pregnancies, with miscarriages in 33% of these. The top answer for the best timing for pregnancy and childbirth was after becoming board-certified. Nearly one-third of first-time mothers experienced adverse events during pregnancy and delivery, and 28% quit or changed their job because of their pregnancy and the birth of their first child. Japanese women who choose a career as a surgeon face obstacles during pregnancy and childbirth. It is vital to share the findings of this study and understand the issues associated with pregnancy and childbirth regardless of gender. Interventions are essential to ensure that every pregnant surgeon has a safe working environment to allow unobstructed development of her career.

Purpose Preoperative pulmonary dysfunction has been associated with increased operative mortality and morbidity after cardiac surgery. This study aimed to determine whether values for the diffusing capacity of the lung for carbon monoxide (DLCO) could predict postoperative complications after cardiac surgery. Methods This study included 408 consecutive patients who underwent cardiac surgery between June 2008 and December 2015. DLCO was routinely determined in all patients. A reduced DLCO was clinically defined as %DLCO CO was calculated as DLCO divided by the predicted DLCO. The association between %DLCO and in-hospital mortality was assessed, and independent predictors of complications were identified by a logistic regression analysis. Results Among the 408 patients, 338 and 70 had %DLCO values of ≥ 70% and P CO (P = 0.275). A multivariate logistic regression analysis with propensity score matching identified reduced DLCO as an independent predictor of complications (OR, 3.270; 95%CI, 1.356–7.882; P = 0.008). Conclusions %DLCO is a powerful predictor of postoperative complications. The preoperative DLCO values might provide information that can be used to accurately predict the prognosis after cardiac surgery. Clinical trial registration number UMIN000029985.

To assess the true conditions and perceptions of the personal lives of men and women working as surgeons in Japan.In 2014, all e-mail subscribed members of the Japan Surgical Society (JSS, n = 29,861) were invited to complete a web-based survey. The questions covered demographic information, work environment, and personal life (including marital status, childcare, and nursing care for adult family members).In total, 6211 surgeons (5586 men and 625 women) returned the questionnaires, representing a response rate of 20.8%. Based on the questionnaire responses, surgeons generally prioritize work and spend most of their time at work, although women with children prioritize their family over work; men spend significantly fewer hours on domestic work/childcare than do their female counterparts (men 0.76 h/day vs. women 2.93 h/day, p 0.01); and both men and women surgeons, regardless of their age or whether they have children, place more importance on the role of women in the family.The personal lives of Japanese surgeons differed significantly according to gender and whether they have children. The conservative idea that women should bear primary responsibility for the family still pertains for both men and women working as surgeons in Japan.

To assess the true conditions and perceptions of the personal lives of men and women working as surgeons in Japan. In 2014, all e-mail subscribed members of the Japan Surgical Society (JSS, n = 29,861) were invited to complete a web-based survey. The questions covered demographic information, work environment, and personal life (including marital status, childcare, and nursing care for adult family members). In total, 6211 surgeons (5586 men and 625 women) returned the questionnaires, representing a response rate of 20.8%. Based on the questionnaire responses, surgeons generally prioritize work and spend most of their time at work, although women with children prioritize their family over work; men spend significantly fewer hours on domestic work/childcare than do their female counterparts (men 0.76 h/day vs. women 2.93 h/day, p

Sarcopenia was assessed as a prognostic factor for patients undergoing cardiac surgery by evaluating the quantity and quality of skeletal muscle. Sarcopenia was assessed by perioperative abdominal computed tomography using the total psoas muscle index (TPI) and intra-muscular adipose tissue content (IMAC). Patients were classified into high- (HT, n = 143) and low- (LT, n = 63) TPI groups and low- (LI, n = 122) and high- (HI, n = 84) IMAC groups. There were significantly more complications in the LT and HI groups than in the HT and LI groups. (HT 15.4% vs. LT 30.2%, P = 0.014) (LI 11.5% vs. HI 31.1%, P

Objectives: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. We investigated the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. Methods: In total, 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by ELISA. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. Results: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels, perioperative data (urine output), ICU stay period, and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. In multivariable logistic regression analysis, the preoperative ET-1 level and CPB time were the independent determinants of AKI, even adjusted by age, sex, and BMI. The preoperative GDF-15 level, CPB time, and RCC transfusion were independent determinants of 30-day mortality plus morbidity. Conclusion: Preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risks for patients undergoing cardiovascular surgery.

Objectives The purpose of this study was to calculate the changes in the blood flow direction and volume in the aortic lumen and at the entry and re-entry sites using 4-dimensional (4D) phase-contrast magnetic resonance imaging (MRI) after performing entry closure with thoracic endovascular aortic repair for chronic DeBakey IIIb aortic dissection. Methods Aortic blood flow was analysed at 3 phases with 4D phase-contrast MRI in a single therapeutic DeBakey IIIb aortic dissection case. Results Primary entry was in the distal arch, and there were 4 re-entry sites downstream in the diaphragm. Preoperatively, the entry site formed a large antegrade flow (1082 ml/min) to the 4 re-entry sites, but soon after the closure of the entry site, re-entry sites 1 through 3 became a new entry site whose flow pattern changed retrogradely, resulting in increased volume in the false lumen in the acute phase, whereas the flow at the previous re-entry sites from the true lumen to the false lumen decreased gradually, resulting in aortic remodelling with a reduction in the size of the false lumen: the preoperative, postoperative and 6-month postoperative mean flow volumes (ml/min) were 23, 254 and 173 at re-entry site 1; 59, 887 and 279 at re-entry site 2; and 303, 608 and 103 at re-entry site 3. The changes in the flow volume of the false lumen followed a similar trend expect for the area around the abdominal aorta. Conclusions The volume of flow at the entry site was high, and closure of the primary entry site during thoracic endovascular aortic repair is very important. These changes in the flow volume of the re-entry sites and the false lumen may affect volume changes in the false lumen.

Objective: The objective of this study was to determine the effects of a continuous infusion of low-dose hANP on the lungs during cardiac surgery in patients under cardiopulmonary bypass (CPB). Methods: We analyzed 30 consecutive cases of cardiac surgery performed at our hospital from 2007–2008. The patients were divided into a group that received hANP (hANP group) or a group that received saline and no hANP (N-hANP group). We measured various parameters before and after surgery using a PiCCO monitor. Result: There were no differences in the preoperative characteristics between the groups, although urine volume during the operation was significantly greater in the hANP group. After surgery, there were no significant differences between the groups in cardiac output index (CI), global enddiastolic volume index (GEDVI), intrathoracic blood volume index (ITBI), pulmonary blood volume index (PBI), extravascular lung water index (ELWI) and pulmonary vascular permeability index (PVPI), total protein, and creatine. In contrast, interleukin-6 (IL-6) and renin were significantly lower, and albumin was significantly higher in the hANP group. Conclusion: We found that low-dose hANP during open cardiac surgery inhibited the secretion and plasma activity of IL-6 and renin. Although there were no differences in lung circulatory parameters such as the amount of fluid in the pulmonary blood vessels between the two groups, we believe that the strong diuretic effect of hANP reduced third-space fluid retention caused by CPB.

Leptin and adiponectin are important regulators of energy metabolism and body composition. Leptin exerts cardiodepressive effects, whereas adiponectin has cardioprotective effects, but several conflicting findings have been reported. The aim of the present study was to assess the relationship between serum leptin and adiponectin levels and echocardiographic parameters and pathophysiological states in patients with cardiovascular disease (CVD) receiving cardiovascular surgery. A total of 128 patients (79 males, average age 69.6 years) that had surgery for CVD including coronary artery bypass graft (CABG) and valve replacement were recruited in this study. Preoperative serum adiponectin and leptin concentrations were measured by enzyme-linked immunosorbent assay and compared with preoperative echocardiographic findings. Body fat volume and skeletal muscle volume index (SMI) were estimated using bioelectrical impedance analysis. We also measured grip strength and gait speed. Sarcopenia was diagnosed based on the recommendations of the Asian Working Group on Sarcopenia. Positive correlations were found between adiponectin and brain natriuretic peptide (BNP), age, left atrial diameter (LAD), E/e’ (early-diastolic left ventricular inflow velocity / early-diastolic mitral annular velocity), and left atrial volume index (LAVI). Negative correlations were observed between adiponectin and body mass index (BMI), estimated glomerular filtration rate (eGFR), triglyceride, hemoglobin, and albumin. Serum leptin was positively correlated with BMI, total cholesterol, triglyceride, albumin, body fat volume, and LV ejection fraction (LVEF), whereas it was negatively correlated with BNP and echocardiographic parameters (LAD, LV mass index (LVMI), and LAVI). Multiple regression analysis showed associations between log (leptin) and log (adiponectin) and echocardiographic parameters after adjusting for age, sex, and BMI. Serum adiponectin was negatively correlated with leptin, but positively correlated with tumor necrosis factor α (TNFα), an inflammatory cytokine. In males, serum leptin level had a positive correlation with skeletal muscle volume and SMI. However, adiponectin had a negative correlation with anterior mid-thigh muscle thickness, skeletal muscle volume and SMI. And, it was an independent predictive factor in males for sarcopenia even after adjusted by age. These results suggest that leptin and adiponectin may play a role in cardiac remodeling in CVD patients receiving cardiovascular surgery. And, adiponectin appears to be a marker of impaired metabolic signaling that is linked to heart failure progression including inflammation, poor nutrition, and muscle wasting in CVD patients receiving cardiovascular surgery.

Frailty and sarcopenia increase the risk of complications and mortality when invasive treatment such as cardiac surgery is performed. Growth differentiation factor-15 (GDF-15) involves various pathophysiological conditions including renal dysfunction, heart failure and cachexia. We investigated the pathophysiological roles of preoperative GDF-15 levels in cardiovascular surgery patients. Preoperative skeletal muscle index (SMI) determined by bioelectrical impedance analysis, hand-grip strength, 4 m gait speed, and anterior thigh muscle thickness (TMth) measured by echocardiography were assessed in 72 patients (average age 69.9 years) who underwent cardiovascular surgery. The preoperative serum GDF-15 concentration was determined by enzyme-linked immunosorbent assay. Circulating GDF-15 level was correlated with age, brain natriuretic peptide, and estimated glomerular filtration rate (eGFR). It was also negatively correlated with SMI, hand-grip strength, and anterior TMth. In multivariate analysis, eGFR and anterior TMth were the independent determinants of GDF-15 concentration even after adjusting for age, sex, and body mass index. Alternatively, the GDF-15 level was an independent determinant of eGFR and anterior TMth. We concluded that preoperative GDF-15 levels reflect muscle wasting as well as renal dysfunction in preoperative cardiovascular surgery patients. GDF-15 may be a novel biomarker for identify high-risk patients with muscle wasting and renal dysfunction before cardiovascular surgery.

A 56-year-old woman with dilated cardiomyopathy underwent mitral and tricuspid annuloplasty, and simultaneous deployment of an extracorporeal left ventricular assist device (LVAD). Subsequently, she developed hemolytic anemia. Although the LVAD system was repeatedly exchanged and the mitral annular ring was removed, her hemolytic anemia did not improve. Finally, the NIPRO LVAD was replaced with Gyro Pump®, and her anemia was ameliorated. It appears important to consider the possibility of hemolytic anemia as a LVAD-related complication, although it would be rare.

Pro-brain natriuretic peptide (proBNP)-108 and N-terminal proBNP-76 (NT-BNP) contain seven sites for O-linked oligosaccharide attachment. Currently, levels of glycosylated NT-BNP are probably underestimated because it is not recognised by one antibody in the sandwich assay system. The pathophysiological significance of cardiac and plasma levels of non-glycosylated (nonglyNT-BNP) and glycosylated NT-BNP (glyNT-BNP) in heart failure (HF) and chronic renal failure (CRF) was investigated.Plasma samples from 186 patients with HF and 76 patients with CRF on haemodialysis were studied, together with 11 atrial tissue samples. To measure nonglyNT-BNP and glyNT-BNP, samples were incubated with or without deglycosylating enzymes and NT-BNP was measured using Roche Elecsys proBNP I. The percentage glyNT-BNP was calculated as glyNT-BNP/(glyNT-BNP + nonglyNT-BNP).In HF, plasma BNP, nonglyNT-BNP and glyNT-BNP levels all increased with increasing disease severity (New York Heart Association class; p0.0001), though the molar ratio remained constant (molar ratio, BNP:nonglyNT-BNP:glyNT-BNP = 1:2.4:9.6). Before haemodialysis for CRF, plasma BNP and nonglyNT-BNP were somewhat elevated, and glyNT-BNP was markedly increased (molar ratio, BNP:nonglyNT-BNP:glyNT-BNP = 1:8.5:82). After haemodialysis, plasma BNP, nonglyNT-BNP, atrial natriuretic protein and cGMP all declined (p0.0001), but glyNT-BNP was unchanged. Notably, the percentage of glyNT-BNP was elevated before haemodialysis, and was further increased after haemodialysis (p0.0001). Atrial tissue levels of BNP, nonglyNT-BNP and glyNT-BNP were similar.THE findings suggest that most endogenous plasma NT-BNP is glycosylated and therefore undetectable with the current assay system, and that the relative glycosylation level is increased by haemodialysis.

Continuous-flow left ventricular assist devices (LVADs) provide acceptable clinical results, but the long waiting period for heart transplantation leads to diverse complications. LVAD support can cause reverse left ventricular (LV) remodeling that results in the improvement of LV function and allows LVAD removal. We present a case of successful removal of a DuraHeart LVAD because of sufficient recovery of LV function. Before LVAD removal, we conducted an "LVAD weaning test" by decreasing pump speed and performing an additional normal saline infusion test. We consider that the LVAD weaning test can be used in place of the "pulsatile LVAD off test."

In the final step of production of adrenomedullin (AM), an inactive intermediate form of glycine-extended AM (AM-glycine) is converted to the active mature form of adrenomedullin (AM-mature) by enzymatic amidation. Recent studies have revealed that AM-mature and AM-glycine circulate in human plasma. In this study, we investigated the differences of the concentrations of cardiac AM between pressure-overloaded (PO) heart failure (HF) and volume-overloaded (VO)-HF in humans.We measured AM-mature and AM-glycine by immunoradiometric assays in pericardial fluid and plasma in 38 patients who underwent valve replacement surgery (PO-HF: aortic stenosis, n=14; VO-HF: aortic or mitral regurgitation, n=24). Stable coronary artery disease with normal left ventricular function served as the control (n=24). Plasma AM-mature (VO-HF: +59%, PO-HF: +65%, P.05) and AM-glycine (VO-HF: +43%, PO-HF: +50%, P0.05) were similarly higher in the 2 HF groups than in the control group. Interestingly, pericardial fluid AM-mature was markedly higher than that in plasma (control: +789%, VO-HF: +1050%, PO-HF: +1745%, all P.001). Pericardial fluid AM-mature was higher in VO-HF (+106%, P.01) than in controls and they were further increased in PO-HF (+243%, P.05). Pericardial fluid molecular forms of AM correlated with left ventricular systolic pressure, but not with left ventricular end-diastolic volume index in PO-HF. In contrast, they correlated with left ventricular end-diastolic volume index, but not with left ventricular systolic pressure in VO-HF.These results suggest that cardiac AM is differently regulated from plasma AM and that cardiac AM production is upregulated in both types of HF in response to each different stimulus.

体重4.1～11.0kgの5症例(両大血管右室起始症:2例,大血管転位症:3例)に対し,同種血非使用の二期的Jatene手術を施行した.術後の循環および呼吸動態は良好で,ICU帰室時の中心静脈圧は9.0～14.5cmH2O(平均12.5cmH2O),術後の人工呼吸器管理時間は3.5～18.0時間(平均7.8時間)であった.麻酔導入後の自己血貯血と人工心肺回路の低容量化は,とくに本術式のような長時間体外循環を必要とする同種血非使用開心術に有用な手段であった.

Experimental studies have demonstrated that adrenomedullin (AM) has a positive inotropic action and exerts inhibitory effects against ventricular remodelling as an autocrine and paracrine factor. However, there is no clinical evidence for AM acting as a local regulator in the human heart. We measured the levels of various molecular forms of AM, i.e. an active form of mature AM (AM-m), an intermediate inactive form of glycine-extended AM (AM-Gly) and total AM (AM-T = AM-m+AM-Gly), in plasma and pericardial fluid using our newly developed immunoradiometric assay in consecutive 67 patients undergoing coronary artery bypass graft surgery. Pericardial fluid and plasma cAMP, atrial natriuretic peptide and brain natriuretic peptide levels were also measured. The relationships between pericardial fluid AM levels and ventricular functions and other hormone levels were analysed. The level of each molecular form of AM in pericardial fluid was closely correlated with that of the other molecular forms of AM in the fluid. However, levels were not correlated with those in plasma. AM-T levels were slightly higher in pericardial fluid than in plasma (+72%; P

Background & Aims : Although aortic valve replacement (AVR) is the only effective treatment for patients with aortic stenosis (AS), it is generally recognized that the surgical risk increases with age.Methods : We examined the outcome of surgical management for AS in patients above 70 years of age in comparison with younger ones to determine whether age was a risk factor.Results : We obtained relatively good results in 3-and 5-year mortality (17% and 25%) in the elder group which were not significantly different from the younger group (5% and 13%). Perioperative factors were not significantly different between the two group. Elderly patients had significantly smaller body surface areas (BSAs) (1.43 ± 0.15 vs. 1.53 ± 0.16m2) and smaller valves (20.5 ± 1.8 vs. 22.0±2.0mm). The age was significantly correlated with the BSA (correlation coefficient=-0.433, p