Association Between the Redox State of Human Serum Albumin and Exercise Capacity in Patients With Cardiac Disease

The redox state of human serum albumin (HSA) is reported to be an oxidative stress biomarker; however, its clinical use in cardiac disease has not yet been examined. This study aimed to investigate the relation between the redox state of HSA and exercise capacity, which is a robust prognostic factor, in patients with cardiovascular disease. This cross-sectional study included outpatients with cardiac disease. Exercise capacity was assessed by peak oxygen consumption (peakVO₂) measured using symptom-limited cardiopulmonary exercise testing. The high-performance liquid chromatography postcolumn bromocresol green method was used to part HSA into human nonmercaptalbumin (oxidized form) and human mercaptalbumin (HMA, reduced form). The fraction of human mercaptalbumin found in HSA (f[HMA]) was calculated as an indicator of the redox state of HSA. The association between peakVO₂ and f(HMA) was examined using the Spearman correlation coefficient and multivariate linear regression analysis. A total of 70 patients were included (median age 76 years; 44 men; median peakVO₂ 15.5 ml/kg/min). The f(HMA) was positively correlated with peakVO₂ (r = 0.38, p <0.01). Even after controlling for potential confounders, this association remained in the multivariate linear regression analysis (standardized beta = 0.24, p <0.05). We found a positive association between f(HMA) and peakVO₂, independent of potential confounders in patients with cardiac disease, suggesting that f(HMA) may be a novel biomarker related to exercise capacity in cardiac disease. Longitudinal studies are required to further examine the prognostic capability of f(HMA), the responsiveness to clinical intervention, and the association between f(HMA) and cardiac disease.

Novel Brain Protection Method for Zone 0 Endovascular Aortic Repair with Selective Cerebral Perfusion

Objective: Zone 0 thoracic endovascular aortic repair (TEVAR) is associated with a high incidence of cerebral infarction mostly due to the embolic shower of a plaque from the aortic arch when the stent graft brushes against the aortic wall. Thus, it is important to develop a method for protecting the brain from such embolism. We report the outcomes of Zone 0 TEVAR with a novel brain protection method using selective cerebral perfusion under extracorporeal membrane oxygenation (ECMO).

Materials and Methods: Two T-shaped grafts with ringed expanded polytetrafluoroethylene (ePTFE) were created using an 8-mm-ringed ePTFE anastomosed end-to-side with a 7-mm-ringed ePTFE. Carotid–carotid bypass and axillo-axillary bypass were established using these grafts. ECMO was connected to the grafts and the femoral vein. Bilateral carotid and axillary arteries were blocked, and cerebral perfusion was selectively maintained using ECMO. Total endovascular Zone 0 TEVAR was performed. The patency of brachiocephalic artery was maintained using the chimney or in situ fenestration technique.

Results: Since August 2016, seven patients with aortic arch aneurysms underwent the procedure. The mortality rate was 0%. No neurological complications developed.

Conclusion: This brain protection method using selective cerebral perfusion under ECMO is a safe method for Zone 0 TEVAR.

Successful Two-Stage Treatment for Coarctation of the Aorta-postductal Type and Aortic Regurgitation with Thoracic Endovascular Aortic Repair and Aortic Valve Replacement

We herein report a case of a 20-year-old man with aortic regurgitation (AR), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). The preoperative ankle–brachial pressure index was 0.56 in bilateral extremities. Enhanced computed tomography revealed CoA-postductal type. We decided to perform a two-stage surgery: thoracic endovascular aortic repair (TEVAR) for CoA and PDA and then open surgery for AR. TEVAR was successfully performed with deployment of the stent graft at a 31-mm diameter subsequent to balloon dilation. At 8 days after TEVAR, the patient underwent aortic valve replacement via median sternotomy and was discharged without a complication.

Prospective validation of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I in Japanese patients presenting to emergency department

Background

The diagnostic performance of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I (hsTnI) for non-ST-segment elevation myocardial infarction (NSTEMI) has not been evaluated in an Asian population.

Purpose

We aimed to prospectively validate the 0-hour/1-hour algorithm using hsTnI in a Japanese population.

Method

We enrolled 754 Japanese patients (mean age of 70 years, 395 men) presenting to our emergency department with symptoms suggestive of NSTEMI. The hsTnI concentration was measured using the Siemens ADVIA Centaur hsTnI assay at presentation and after 1 hour. Patients were divided into three groups according to the algorithm: hsTnI below 3 ng/L (only applicable if chest pain onset &gt;3 hours) or below 6 ng/L and delta 1 hour below 3 ng/L were the “rule-out” group; hsTnI at least 120 ng/L or delta 1 hour at least 12 ng/L were in the “rule-in” group; the remaining patients were classified as the “observe” group. Based on the Fourth Universal Definition of Myocardial Infarction, the final diagnosis was adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, and follow-up data. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 hour.

Results

Prevalence of NSTEMI was 6.5%. The safety of rule-out (NPV 100%), accuracy of rule-in (PPV 26%), and overall efficacy (54%) were shown in Figure.

Conclusion

The 0-hour/1-hour algorithm using hsTnI is very safe and effective in triaging Japanese patients with suspected NSTEMI.

Funding Acknowledgement

Type of funding source: None

Clinical Application of an Original Flexible MK Stent-Graft for Nonruptured Thoracic Aortic Aneurysms: Early Experience

Objective

To obtain early MK stent-grafting results for nonruptured thoracic aortic aneurysms and thoracoabdominal aortic aneurysms.

Methods

The authors analyzed 47 patients who underwent treatment using MK stent-grafting. All patients (40 men and 7 women; mean age, 70.8 years) underwent elective procedures. Straight, curved, or tapered MK stents were constructed from a nitinol wire and covered with seamless, cylindrical woven polyester fabric grafts. The mean stent-graft diameter was 24 to 48 mm. In cases where the aneurysm had a short proximal neck (under 15 mm), supraaortic arch artery bypass surgery was planned to lengthen the neck.

Results

Simple stent-grafting without bypass was performed in 26 patients, whereas stent-grafting with supraaortic arch artery bypass was performed in 21 patients. An 18 or 20 F sheath was used as the delivery system in 46 patients (96%). In all 47 patients, the stent-grafts were successfully deployed. Two patients died while in hospital, and another 2 patients suffered a stroke. No other perioperative complications were observed. Postoperative computed tomography after 3 months showed complete thrombus formation in 42 patients (93.3%; 42/45 patients).

Conclusions

Forty-seven patients with thoracic aortic aneurysm were treated with our original flexible MK stent-graft system. Using a small sheath system, straight or curved M-K stent-grafts could be deployed to adequately fit to the aorta as planned. Furthermore, simultaneous bypass surgery widened the application of stent-grafting. However, careful long-term observation is necessary, and further studies are needed to assess such stent-grafting with bypass surgery.

Nonresectional Simplified Folding Technique in Robotic Mitral Valve Plasty: Comparison with Leaflet Resection Technique

OBJECTIVE

The mitral valve plasty (MVP) technique for degenerative disease is typically leaflet resection and suturing. However, this technique is time consuming and unreproducible. To overcome this disadvantage, we developed a nonresectional folding technique, which is fast and reproducible. In this report, we examine our new folding technique in robotic MVP.

METHODS

The new folding technique was performed in 10 patients (age 56 ± 15 years), and the conventional resection and suturing (RS) technique was performed in 22 patients (age 53 ± 8 years). In our new folding technique, we used two sutures to fold the prolapsed leaflet to the left ventricle side. The first folding suture line is a land mark, and the second line adjusts the height of the posterior leaflet to the anterior leaflet so that sufficient coaptation depth can be obtained.

RESULTS

MVP was successful in all patients. In the folding technique group, the operation time, cardiopulmonary bypass time, and cross clamp time was faster than the conventional RS technique group (188 ± 31, 97 ± 32, and 55 ± 3 min, versus 242 ± 51, 137 ± 25, and 70 ± 15 min; P < .05). Hospital stays were significantly shorter in the folding technique group (13 ± 2 days versus 17 ± 7 days; P < .05). All patients were discharged without complications. The post-echocardiography revealed no mitral valve regurgitation in any patient.

CONCLUSION

The new folding technique facilitated efficient MVP for posterior leaflet prolapse in mitral valve regurgitation, without the need for the resection of the leaflet.

Robotic mitral valve plasty for mitral regurgitation after blunt chest trauma in Barlow's disease

We successfully treated a case of mitral regurgitation due to chest trauma in Barlow's disease. A 71-year-old man was admitted with severe mitral regurgitation after blunt compression of the chest by a heavy object 5 months earlier. Preoperative examination revealed wide chordae tendineae rupture and myxomatous changes to the bileaflets. Neo-chordae reconstruction of the anterior mitral leaflet using loop technique, triangular resection of the posterior mitral leaflet, and ring annuloplasty was performed via surgical robot. Robotic mitral valve plasty for severe mitral regurgitation due to chest trauma in Barlow's disease was achieved safely with good clinical and excellent cosmetic results.

Surgical Repair for the Treatment of Pulmonary Vein Stenosis After Radiofrequency Ablation

Radiofrequency ablation procedures for atrial fibrillation are occasionally associated with pulmonary vein stenosis (PVS). A common treatment for PVS is catheter intervention; however, because of the high restenosis rate, it is not suitable for young patients. The case presented herein is of a young male patient with severe bilateral PVS who underwent successful surgical pulmonary vein repair by sutureless technique. The stenotic lesions of the pulmonary veins were dissected and were covered using autologous pericardium. An enhanced computed tomographic scan revealed that all the pulmonary veins were widely patent after 6 months from the operation.

[Emergency Thoracic Endovascular Aortic Repair of Ruptured Kommerell's Diverticulum with an Acute Aortic Dissection]

This case report describes emergency thoracic endovascular aortic repair (TEVAR) of a ruptured Kommerell's diverticulum associated with a type B acute aortic dissection in a patient with a right aortic arch. A 64-year-old male was admitted with symptoms of sudden paraplegia and shock. The computed tomography imaging showed right aortic arch anomaly, with mirror image branching of the major arteries. The aorta was dissected from the origin of the right subclavian artery to the terminal aorta, with a thrombosed false lumen. Rupture was found in a 6.3 cm aneurysm located in the distal arch, which was diagnosed as Kommerell's diverticulum. We performed emergency TEVAR, and the aneurysm was successfully excluded using deployment of a Gore Tag stent-graft. At 3 months' follow-up, the patient was doing well and showed shrinkage of the aneurysm was confirmed. TEVAR is considered to be a suitable procedure for an emergency aortic catastrophe even in patients with aortic anomaly.

Totally endoscopic robotic resection of left atrial myxoma with persistent left superior vena cava

A 68-year old man with a cardiac tumour was admitted for robotic tumour resection using the da Vinci S Surgical System. While undergoing preoperative examination, he was found to have a persistent left superior vena cava. After general anaesthesia and single-lung ventilation, cardiopulmonary bypass was established, with venous drainage through bilateral internal jugular and right femoral veins and arterial return through the right femoral artery. Robotic tumour resection was performed by four ports in the right chest. There were no difficulties during the operation, and successful tumour resection was achieved with satisfactory margins. He was discharged without complications. Persistent left superior vena cava is very rare, but if diagnosed preoperatively and an appropriate operative plan is made, robotic cardiac surgery can be performed safely. With robotic surgery, cardiac tumour resection can be feasibly performed, with cosmetic benefits.

A novel one-shot circular stapler closure for atrial septal defect in a beating-heart porcine model

PURPOSE

In surgical atrial septal defect (ASD) closure, there are no techniques or devices that can close the ASD accurately in a short time under a beating heart. We have developed a simple and automatic ASD closure technique using a circular stapler. This study assessed the feasibility and efficacy of a new circular stapler closure for ASD.

DESCRIPTION

Under a continuous beating heart, hand-sewn patch plasty ASD closure was performed in 6 pigs (group A) and circular stapler ASD closure was performed in 6 pigs (group B). The time to close the ASD and the effectiveness of the closure were compared.

EVALUATION

Closure was significantly faster in group B (10.5 ± 1.0 seconds) than in group A (664 ± 10 seconds; p < 0.05). There was no leakage at the closure site, and sufficient tolerance was confirmed.

CONCLUSIONS

A circular stapler can be used to treat ASD faster than hand-sewn patch plasty, with sufficient pressure tolerance in a beating heart porcine model.

Robotic resection of dual accessory mitral valve tissue in an adult patient

The presence of isolated accessory mitral valve tissue (AMVT) is extremely rare in adults. We successfully performed robot-assisted resection of dual AMVT that was attached to the papillary muscle and anterior mitral leaflet. Echocardiography was invaluable for identifying the most suitable approach. The short-axis view on echocardiography revealed the precise location where the AMVT was attached. The robotic operation enabled fine visualization; we clearly observed the AMVT and removed its entire extra structure. The patient recovered well and was discharged 3 days after the operation. To the best of our knowledge, this is the first report of successful robotic AMVT resection.

Kidney fibrosis is independent of the amount of ascorbic acid in mice with unilateral ureteral obstruction

In response to sustained damage to a kidney, fibrosis that can be characterized as the deposition of a collagenous matrix occurs and consequently causes chronic kidney failure. Because most animals used in experiments synthesize ascorbic acid (AsA) from glucose, the roles of AsA in fibrotic kidney diseases are largely unknown. Unilateral ureteric obstruction (UUO) mimics the complex pathophysiology of chronic obstructive nephropathy and is an ideal model for the investigation of the roles of AsA in kidney failure. We examined the impact of a deficiency of Akr1a, a gene that encodes aldehyde reductase and is responsible for the production of AsA, on fibrotic damage caused by UUO in mice. Oxidatively modified DNA was elevated in wild-type and Akr1a-deficient kidneys as a result of UUO to a similar extent, and was only slightly suppressed by the administration of AsA. Even though Akrla-deficient mice could produce only about 10% of the AsA produced by wild-type mice, no difference was observed in collagen I synthesis under pathological conditions. The data implied either a low demand for AsA or the presence of another electron donor for collagen I production in the mouse kidney. Next, we attempted to elucidate the potential causes for oxidative damage in kidney cells during the fibrotic change. We found decreases in mitochondrial proteins, particularly in electron transport complexes, at the initial stage of the kidney fibrosis. The data imply that a dysfunction of the mitochondria leads to an elevation of ROS, which results in kidney fibrosis by stimulating cellular transformation to myofibroblasts.

A Simple, Natural and Effective Framework of Nonlinear Systems Control and its Application to Aerial Robots

This paper presents a simple, natural and effective framework of nonlinear systems control and its application to aerial robots. First, we present a framework of Takagi-Sugeno fuzzy model-based control and also discuss its feature. Next, a number of design problems for the control framework are formulated as numerically feasibility problems of representing in terms of linear matrix inequalities. Finally, we provide two applications of the control framework to aerial robots. The control results of aerial robots show the utility of the control framework.

En bloc vascular resection for the treatment of borderline resectable pancreatic head carcinoma

Borderline resectable (BR) pancreatic head carcinoma (PhC) is an advanced disease, presenting with infiltration of major vessels. Major vascular resection (VR), particularly arterial resection, to achieve microscopic no residual tumor (R0) is a controversial approach, due to the potential complications. In this study, we aimed to clarify the benefit of en bloc R0 resection with VR for PhC by retrospectively evaluating 78 PhC patients who underwent pancreatoduodenectomy at our institute. The patients were divided into 4 groups as follows: R, resectable (n=20); BR-V, BR involving the superior mesenteric vein or portal vein (PV) (n=28); BR-SMA, BR involving the superior mesenteric artery (n=21); and BR-HA, BR involving the hepatic artery (n=9). In total, 65 patients underwent VR, with 63, 21 and 9 patients undergoing PV, SMA and HA resection, respectively. The R0 rates were as follows: R group, 85%; BR-V, 82%; BR-SMA, 71%; and BR-HA, 33%. The median survival time and 5-year survival rate for R0 resection were 31 months and 25% in the R group, 22 months and 28% in the BR-V group, 17 months and 27% in the BR-SMA group and 10 months and 0% in the BR-HA group, respectively. The prognosis was comparable among the BR-V, BR-SMA and R groups, but was significantly poorer in the BR-HA group. In total, 5 patients (6.4%) died perioperatively (4 from postoperative hemorrhage and 1 from suffocation due to failure of expectoration, without pneumonia or asthma). Of the 4 patients who succumbed to hemorrhage, 3 had undergone arterial resection. Therefore, en bloc resection with major VR for R0 may be suitable for BR-V and BR-SMA PhC patients.

A novel coronary active perfusion system using a conventional intra-aortic balloon pump for off-pump coronary artery bypass grafting

OBJECTIVE

It is important for coronary active perfusion systems to avoid myocardial ischemia during off-pump coronary artery bypass grafting. We have developed a new concept for a perfusion system to pump blood based on changes in helium gas volume. This system uses a conventional intra-aortic balloon pump to activate the perfusion pump. Our study used basic and animal experiments to investigate the most suitable system for coronary perfusion using this new concept.

METHODS

A conventional intra-aortic balloon pump was used to supply power. A device for perfusion was developed with a balloon placed inside a stiff syringe barrel. The device was connected to the helium gas line of the intra-aortic balloon pump. Changes in flow with changes in augmentation level were noted when volumes outside and within the balloon were changed. Six pigs with occlusion of the left anterior descending artery were used for system validation, with monitoring to identify changes in hemodynamics and cardiac enzyme levels.

RESULTS

In the basic experiment, an 80-mL outside volume and 3.0-mL inner volume resulted in the greatest percentage change in flow rate with respect to changes in augmentation. In the animal experiment, the new coronary active perfusion system prevented myocardial ischemia during coronary occlusion.

CONCLUSIONS

We clarified the most suitable method for our new coronary active perfusion system. Using this system, safe anastomosis was consistently performed in animal experiments. Clinically, off-pump coronary artery bypass may potentially be performed more safely and easily using this new system.

Endovascular repair of a traumatic thoracic aortic injury resulting in late aortic dilatation

We present an unusual complication following endovascular repair of traumatic thoracic aortic injury using a homemade stent-graft. Although an initial technical success was apparently obtained, the aorta showed remarkable dilatation without shortening or migration of the stent skeleton in late follow-up period. The possible cause of the dilatation was considered to be the expansion and gathering of the crimped, loosely attached, graft fabric in addition to the incomplete exclusion due to the insufficient landing zone and the limited radial force. Thus, the specific feature of stent-graft, considered to provide an advantage to treatment, has adversely affected the native aorta.