Frailty assessment using photographs in patients undergoing transcatheter aortic valve replacement

BACKGROUND

When frailty is considered in patient selection, better outcomes are achieved in transcatheter aortic valve replacement (TAVR) procedures. This study investigated whether patient photographs could be utilized to qualitatively assess patient frailty and independently predict poor outcomes following TAVR.

METHODS

This study included 1345 patients with severe aortic stenosis who underwent TAVR at the Sakakibara Heart Institute, Japan, between 2013 and 2022. Patient photographs were taken prior to the initial outpatient clinic examination or at discharge in case the patient's first visit was unplanned admission. Frailty was assessed from patient photographs using a four-point photographic frailty scale; 1 (non-frail), 2 (vulnerable), 3 (mild frail), and 4 (frail). Photographic frailty scale of 3 and 4 were defined as high. The primary endpoint was all-cause mortality following TAVR.

RESULTS

Seven hundred ninety-six patients who had their facial photographs taken within six months before the TAVR procedure were analyzed. Patients with a higher photographic frailty scale belonged to New York Heart Association classes III/IV, and had higher Society of Thoracic Surgeons scores, higher incidence of wheelchair usage, lower hemoglobin, and smaller aortic valve areas. According to the frailty assessment, patients with a higher photographic frailty scale exhibited slower performance in the 5-m walk test, reduced hand grip strength, more severe dementia, had a higher clinical frailty scale, and lower serum albumin level. Multivariable Cox regression analysis revealed that the high photographic frailty scale was independently associated with all-cause mortality (adjusted hazard ratio 1.62, 95 % confidence interval 1.12-2.33, p = 0.010). Kaplan-Meier analysis indicated that patients with high photographic frailty scale had higher all-cause mortality rates compared to those with low scale (log-rank p = 0.011).

CONCLUSIONS

Patient registration photographs can be used to obtain qualitative assessments of frailty in severe aortic stenosis cases, and such assessments can independently predict poor outcomes following TAVR.

Impact of osteoporotic risk in women undergoing transcatheter aortic valve replacement

Low body weight and advanced age are reported to be among the best predictors of osteoporosis, and osteoporosis self-assessment tool (OST) values are calculated using a simple formula to identify postmenopausal women at increased risk of osteoporosis. In our recent study, we demonstrated an association between fractures and poor outcomes in postmenopausal women following transcatheter aortic valve replacement (TAVR). In this study, we aimed to investigate the osteoporotic risk in women with severe aortic stenosis and determined whether an OST could predict all-cause mortality following TAVR. The study population comprised 619 women who underwent TAVR. Compared to a quarter of patients with diagnosis of osteoporosis, 92.4% of participants were at high risk of osteoporosis based on OST criteria. When divided into tertiles based on OST values, patients in tertile 1 (lowest OST) displayed increased frailty, a higher incidence of multiple fractures, and greater Society of Thoracic Surgeons scores. Estimated all-cause mortality survival rates 3 years post-TAVR were 84.2 ± 3.0%, 89.5 ± 2.6%, and 96.9 ± 1.7% for OST tertiles 1, 2, and 3, respectively (p = 0.001). Multivariate analysis showed that the OST tertile 3 was associated with decreased risk of all-cause mortality compared with OST tertile 1 as the referent. Notably, a history of osteoporosis was not associated with all-cause mortality. Patients with high osteoporotic risk are highly prevalent among those with aortic stenosis according to the OST criteria. OST value is a useful marker for predicting all-cause mortality in patients undergoing TAVR.

Concomitant Use of Multiple Nephrotoxins including Renal Hypoperfusion Medications Causes Vancomycin-Associated Nephrotoxicity: Combined Retrospective Analyses of Two Real-World Databases

There is a growing concern about the relationship between vancomycin-associated nephrotoxicity (VAN) and concomitant use of nephrotoxins. We examined this relationship by combined retrospective analyses of two real-world databases. Initially, the FDA Adverse Event Reporting System (FAERS) was analyzed for the effects of concomitant use of one or more nephrotoxins on VAN and the types of combinations of nephrotoxins that exacerbate VAN. Next, electronic medical records (EMRs) of patients who received vancomycin (VCM) at Tokushima University Hospital between January 2006 and March 2019 were examined to confirm the FAERS analysis. An elevated reporting odds ratio (ROR) was observed with increases in the number of nephrotoxins administered (VCM + one nephrotoxin, adjusted ROR (95% confidence interval [CI]) 1.67 [1.51-1.85]; VCM + ≥2 nephrotoxins, adjusted ROR [95% CI] 1.54 [1.37-1.73]) in FAERS. EMRs analysis showed that the number of nephrotoxins was associated with higher incidences of VAN [odds ratio: 1.99; 95% CI: 1.42-2.78]. Overall, concomitant use of nephrotoxins was associated with an increased incidence of VAN, especially when at least one of those nephrotoxins was a renal hypoperfusion medication (furosemide, non-steroidal anti-inflammatory drugs, and vasopressors). The concomitant use of multiple nephrotoxins, especially including renal hypoperfusion medication, should be avoided to prevent VAN.

Transcatheter edge-to-edge mitral valve repair with extended clip arms for ventricular functional mitral regurgitation

BACKGROUND

The new sizing options of the MitraClip system (Abbott Vascular, Abbott Park, IL, USA) with extended clip arms were recently developed. Its applicability and effectiveness for ventricular functional mitral regurgitation (VFMR) are yet to be investigated.

METHODS

We retrospectively reviewed consecutive patients with symptomatic VFMR who underwent transcatheter edge-to-edge repair between 2018 and 2022 at the Sakakibara Heart Institute. Pre- and post-procedural mitral valve morphologies were assessed using three-dimensional transesophageal echocardiography.

RESULTS

In a total of 104 VFMR patients, the posterior mitral leaflet length was 12.8 ± 2.8 mm and 92 % was indicative of the extended arm (≥9 mm). Although baseline VFMR was more severe in the patients treated with the extended arms (n = 35, XT group) than the patients treated with the standard arms (n = 69, NT group), the decrease in VFMR was greater in the XT group (delta three-dimensional vena contracta area - 43 ± 33 mm2 vs. -31 ± 22 mm2, p = 0.030) and residual VFMR was similar between the groups, with a significantly greater reduction in the mitral annulus anterior-posterior diameter (-4.9 ± 2.2 mm vs -3.1 ± 2.1 mm, p < 0.001) and mitral annulus area in the XT group. The use of extended arms was independently associated with shorter procedure time (81 ± 26 min vs 108 ± 41 min) after adjustment for device generation and the number of clips (p = 0.017).

CONCLUSIONS

Most VFMR patients had enough leaflet lengths for transcatheter edge-to-edge repair using the MitraClip with the extended arms, which was associated with shorter procedure time and a greater decrease in the mitral annular size.

Cardiac Reversibility and Survival After Transcatheter Aortic Valve Implantation in Patients With Low-Gradient Aortic Stenosis

Background Prognostic implications of transcatheter aortic valve implantation (TAVI) in low-gradient (LG) aortic stenosis (AS) remain controversial. The authors hypothesized that differences in cardiac functional recovery may solve this ongoing controversy. The aim was to evaluate clinical outcomes and the response of left ventricular (LV) function following TAVI in patients with LG AS. Methods and Results This multicenter retrospective study included 1742 patients with severe AS undergoing TAVI between January 2015 and March 2019. Patients were subdivided into low-flow (LF) LG, normal-flow (NF) LG, LF high-gradient, and NF high-gradient AS groups according to the mean gradient of the aortic valve (LG <40 mm Hg) and LV stroke volume index (LF <35 mL/m2). Outcomes and changes in echocardiographic parameters after TAVI were compared between the groups. A total of 227 patients (13%) had reduced ejection fraction, and 486 patients (28%) had LG AS (LF-LG 143 [8%]; NF-LG 343 [20%]). During a median follow-up period of 747 days, 301 patients experienced a composite end point of cardiovascular death and rehospitalization for cardiovascular events, which was higher in the LF-LG and NF-LG groups than in the high-gradient groups. LG AS was independently associated with the primary outcome (hazard ratio, 1.69; P<0.001). Among 1239 patients with follow-up echocardiography, LG AS showed less improvement in the LV mass index and LV end-diastolic volume compared with high-gradient AS after 1 year, while LV recovery was similar between the LF AS and NF AS groups. Conclusions LG AS was associated with poorer outcomes and LV recovery, regardless of flow status after TAVI. Careful evaluation of AS severity may be required in LG AS to provide TAVI within the appropriate time and advanced care afterward.

Efficient one-pot synthesis of dan-substituted organo- and silyl-boron compounds

Direct, transition metal-free B(dan)-installation into organic frameworks has been developed. Heteroaryl-H bonds were transformable into the respective heteroaryl-B(dan) bonds through deprotonation. The resulting heteroaryl-B(dan) compounds, which are otherwise difficult to access, can undergo the direct Suzuki-Miyaura coupling. The method was demonstrated to apply to a silicon nucleophile, giving Lewis acidity-diminished stable silyl-B(dan) and -B(aam) in one pot.

Non-recovery of vancomycin-associated nephrotoxicity is related to worsening survival outcomes-combined retrospective analyses of two real-world databases

There has been growing concern in worsening survival and renal outcomes following vancomycin-associated nephrotoxicity (VAN) onset, but the factors associated with these phenomena remain unclear. To examine these factors, we performed a retrospective study combining the analysis of two real-world databases. Initially, the FDA Adverse Event Reporting System (FAERS) was used to evaluate the relationship between VAN and mortality using odds ratios (ORs) and 95% confidence intervals (CIs). Next, electronic medical records (EMRs) were examined in a more robust cohort for evaluation of the association between renal outcomes and worsening survival using Cox proportional hazards regression models. FAERS analysis revealed a significant correlation between VAN occurrence and increased mortality (OR: 1.30; 95% CI: 1.17-1.46). EMR analysis showed that non-recovery of VAN was associated with increased hospital mortality (hazard ratio [HR]: 4.05; 95% CI: 2.42-6.77) and one-year mortality (HR: 3.03, 95% CI: 1.98-4.64). The HR for VAN recovery was lower for patients with acute kidney injury (AKI) stage ≥ 2 (HR: 0.09; 95% CI: 0.02-0.40). Thus, worsening survival outcomes were associated with non-recovery of VAN, whereby AKI stage ≥ 2 was a significant risk factor. Progression to severe VAN should be prevented for better survival outcomes.

Usefulness of a Pulse Oximeter and Multimodality Imaging for Diagnosing Platypnea-orthodeoxia Syndrome

Platypnea-orthodeoxia syndrome (POS) is a rare disease characterized by dyspnea and hypoxemia in orthostatism that improves in the recumbent position. We herein report an 81-year-old woman with dyspnea in the upright position following thoracic vertebral compression fractures. After the patient's daughter brought a recording showing decreasing SpO₂ (peripheral capillary oxygen saturation) in the upright position as measured by a portable pulse oximeter outside the hospital, a small atrial septal defect (ASD) was detected. A contrast echocardiogram and four-dimensional flow magnetic resonance imaging demonstrated a right-to-left shunt. The patient's symptoms dramatically improved after percutaneous ASD closure. In conclusion, such new technologies are useful for diagnosing POS.

A stable silylborane with diminished boron Lewis acidity

A new dimethyl(phenyl)silylborane having a naphthalene-1,8-diaminato (dan) substituent on the boron center, PhMe₂Si-B(dan), was synthesized. Owing to the diminished boron Lewis acidity, it is highly stable toward air. Synthetic application of the silylborane to catalytic silylboration and silylation of alkynes is also described.

Management of a malpositioned central venous catheter in the accessory hemiazygos vein

Malposition of a central venous catheter (CVC) in the accessory hemiazygos vein is an uncommon but potentially fatal complication; however, there is limited information regarding the preferred removal technique. We report a patient, a 57-year-old woman, who presented with overdose of her prescribed sedatives, who experienced this catheter complication after CVC insertion in the left internal jugular vein. The CVC was placed without resistance but routine postplacement chest X-ray showed abnormal coursing of the catheter close to the descending aorta. We used non-enhanced CT as an adjunct to safely identify the catheter position and assess for any bleeding during removal. CT images taken after retraction of the catheter tip by 10 cm showed no bleeding and we were able to remove the catheter safely. We recommend using CT as an adjunct to safely remove malpositioned catheters and reduce the risk of further complication.

Prevalence, Characteristics, and Impact of Frailty in Patients with Functional Tricuspid Regurgitation

Little is known as regards frailty in patients with functional tricuspid regurgitation (FTR). Thus, in this study, we aimed to investigate the prevalence, characteristics, and impact of frailty on patients with severe FTR.This prospective study included 110 consecutive patients with severe FTR who were assessed via transthoracic echocardiography at an outpatient clinic. Patients were dichotomized using short physical performance battery (SPPB). To better understand the whole picture of frailty in patients with FTR, other frailty scales were also assessed (frailty checklist, clinical frailty scale, gait speed, and Columbia frailty scale). The primary endpoint was the combination of all-cause mortality and heart failure hospitalization.According to each definition of frailty, 28%-46% were identified to be frail. Those with SPPB score of < 9 were older, had greater New York Heart Association (NYHA) functional classification, and had lower albumin level and estimated glomerular filtration rate compared with those with SPPB score of ≥ 9. They also have smaller tricuspid valve coaptation depth and worse right ventricular fractional area change (RV-FAC) than those with SPPB score of ≥ 9 despite having similar TR severity. The primary endpoint at 1 year was noted in 31% of patients. The SPPB score has excellent discriminatory performance for predicting the primary endpoint (area under the curve 0.82, 95% confidence interval [CI] 0.76-0.91) in receiver operating characteristic analysis and was independently associated with the primary endpoint after adjustment in multivariate analysis (adjusted hazard ratio 0.81, 95% CI, 0.73-0.90; P < 0.001).Frailty has been widely prevalent in the elderly patient population with FTR; in fact, it has been determined to be strong parameter for poor outcomes.

Clinical features and significance of leukopenia occurring immediately after endovascular surgery

PURPOSE

Inflammation after stent graft surgery is known as postimplantation syndrome (PIS) and it causes leukocytosis. However, we have experienced leukopenia in the very early postoperative phase of endovascular surgery at our institution. We investigated leukopenia, an under-recognized phenomenon that occurred after transcatheter aortic valve implantation (TAVI), endovascular aortic repair (EVAR), and thoracic endovascular aortic repair (TEVAR).

METHODS

Records of patients who underwent TAVI, EVAR, and TEVAR between March 2018 and February 2019 were retrospectively reviewed. Primary outcomes were the decline rate of white blood cell count (DR-WBC) in the immediate postoperative period and its differences among surgical procedures. The secondary endpoint was the relationship between DR-WBC and infectious complications. Furthermore, the incidence of PIS and its differences among the procedures and associations with DR-WBC were evaluated.

RESULTS

A total of 108 patients (TAVI 41, EVAR 37, TEVAR 30) were included. DR-WBC immediately after surgery was higher in the TAVI group when compared with other groups (TAVI, 43.1 ± 22.6%; EVAR, 27.6 ± 17.3%; TEVAR, 25.4 ± 27.4%; P < 0.01). DR-WBC was not significantly different regardless of postoperative infection (P = 0.45) or PIS (P = 0.62). The incidence rate of PIS was higher in the EVAR group compared with the TAVI group, and was not associated with DR-WBC.

CONCLUSIONS

Leukopenia was a common phenomenon immediately after endovascular surgery, especially TAVI. It resolved a day after surgery and was not associated with PIS or infectious complications. Therefore, it seems to be a transient abnormal hematological finding and a self-limiting condition.

Prevalence and impact of fracture on postmenopausal women with aortic stenosis who underwent transcatheter aortic valve replacement

Information regarding fracture in patients with transcatheter aortic valve replacement (TAVR) is limited. We investigated the prevalence and impact of fracture in patients with severe aortic stenosis who had undergone TAVR. Of 913 consecutive patients with symptomatic, severe aortic stenosis who underwent TAVR at the Sakakibara Heart Institute between October 2013 and April 2020, 633 women were enrolled. The primary endpoint was all-cause mortality following TAVR. Patients with a history of fracture displayed smaller body mass indices, increased frailty, a higher prevalence of osteoporosis, and stroke history. Notably, 61.7% of patients with a history of fracture reported to have not taken any osteoporosis medications. Estimated all-cause mortality survival rates post-TAVR were significantly lower in patients with fractures than those without fractures. In the multivariate analysis, history of fracture was independently associated with all-cause mortality following TAVR. Furthermore, fracture prevalence was significantly greater in those who had a higher clinical frailty scale score were slower in the 5-m walk test, had more severe dementia as per the revised Hasegawa dementia scale, and performed poorly in the hand grip strength test. History of fracture was an independent predictor for all-cause mortality in patients undergoing TAVR. In addition, our study demonstrated that osteoporotic fracture may be under-treated in this population. History of fracture may be one of the phenotypes of frailty given its significant relationship with frailty markers in this population.

Transcatheter aortic valve replacement in patients with extremely severe aortic stenosis

BACKGROUND

Although most patients with severe aortic stenosis (AS) have high aortic valve velocities, outcomes of transcatheter aortic valve replacement (TAVR) in patients with extremely high aortic valve velocities remain unclear. We aimed to investigate the clinical outcomes of patients with peak aortic jet velocity (Vmax) values ≥ 6 m/s.

METHODS

The study included 913 consecutive patients who underwent TAVR between 2013 and 2020. To better understand the impacts of the higher Vmax on outcomes, patients with Vmax values < 4.0 m/s, ejection fractions < 50%, valve-in-valve procedures, and unstable hemodynamics were excluded. Patients were grouped according to preprocedural Vmax as follows: 4-5 m/s, 5-6 m/s, and ≥ 6 m/s. According to guidelines describing Vmax ≥ 5.0 m/s as "very" severe AS, Vmax ≥ 6.0 m/s was defined as "extremely" severe AS in this study.

RESULTS

New York Heart Association classification-III/IV and severe left ventricular hypertrophy were more frequent in the extremely severe AS group, which concurred with the advanced stage of severe AS, and they had a similar mortality rate to the other groups. Although they showed the greatest Vmax improvements after TAVR, they had higher paravalvular leak (PVL) rates. Even among the patients who received newer-generation transcatheter aortic valves, they had higher PVL rates, despite more frequent balloon dilation than the other groups.

CONCLUSION

Although patients with extremely severe AS have similar mortality rates to other patients with severe AS after TAVR, the risk of procedural complications caused by more frequent balloon dilation should be considered.

Modified essential frailty toolset to determine outcomes following transcatheter aortic valve replacement

BACKGROUND

Several predictors are available to guide patient selection for transcatheter aortic valve replacement (TAVR) to achieve better outcomes, and the essential frailty toolset (EFT) has been reported as one of those predictors. This study investigated whether a modified EFT could independently predict all-cause mortality following TAVR.

METHODS

The study population comprised 176 consecutive patients with severe aortic stenosis whose frailty was assessed with a modified EFT prior to TAVR at the Sakakibara Heart Institute between 2013 and 2018. The primary endpoint was all-cause mortality following TAVR. To understand the association between the modified EFT and all-cause mortality, multivariate Cox regression analysis was performed. In addition, to understand its predictive performance, we conducted a receiver operating characteristic (ROC) analysis.

RESULTS

Patients were elderly, relatively frail, and were likely to have significant heart failure symptoms. By the modified EFT definition, 40 patients (22.7%) were considered frail. With a median follow up of 1145 days, all-cause mortality at 1, 2, and 3 years was 6.2%, 10.2%, and 18.3%, respectively. Patients assessed as more frail on the clinical frailty scale had higher modified EFT scores. In ROC analysis, the area under the curve for predicting all-cause mortality at 1, 2, and 3 years was 0.79 [95% confidence interval (CI) 0.68-0.90]; 0.74 (95% CI 0.62-0.84); and 0.67 (95% CI 0.56-0.79), respectively, with the best cut-off modified EFT score of 1/2.

CONCLUSIONS

The modified EFT score was independently associated with all-cause mortality and had excellent predictive performance for all-cause mortality at 1 year.

P1363 Risk factors of severe tricuspid regurgitation after left-sided valve surgery

Background

Tricuspid regurgitation (TR) sometimes deteriorate late after left-sided valve surgery. The recent guidelines recommend tricuspid valve repair at the same time as the left-sided valve surgery. However, little is known about the pathophysiology that leads to severe TR after left-sided valve surgery.

Purpose

To clarify the risk factors of the patients with severe TR after left-sided valve surgery.

Methods

We retrospectively investigated consecutive 526 patients diagnosed as severe TR from January 2004 to December 2018 at our hospital. Clinical background, echocardiographic parameters were evaluated. Demographic information and clinical data (including age, electrocardiograms, type of left-sided valve surgery, underlying valve diseases and history of pacemaker or ICD implantation) were obtained by chart review.

Results

Of the 526 patients with severe TR, 107 patients were after a left-sided valve surgery. Patients developed severe TR at a mean of 14.8 ± 8 years after surgery.The surgical indications were as follows: mitral valve stenosis (74 patients, 69%), mitral valve regurgitation (43 patients, 40%), aortic valve stenosis (37 patients, 35%) and aortic regurgitation (28 patients, 26%), respectively. The mean age at diagnosis of severe TR was 74 ± 10 years and 75 were female (70%). Among those patients, 32 patients (30%) had a tricuspid annuloplasty (TAP) with the first left-sided valve surgery. Ninety-five patients (88%) had atrial fibrillation (AF), 75 patients (70%) were diagnosed as rheumatic heart disease, 64 patients (60%) had pulmonary artery hypertension (PH) and 28 patients (26%) had a permanent pacemaker or ICD implantation.

There were only 12 patients who had severe TR without AF. Eight of 12 patients without AF had PH, and permanent pacemakers were implanted in remaining 4 patients.

Conclusions

Almost all patients with severe TR after left-sided valve surgery present with AF and prevalence of rheumatic heart disease were about 70 percent. These two factors may be one of the important risk factors for severe TR after left-sided valve surgery.

Bisoprolol transdermal patch for perioperative care of non-cardiac surgery in patients with hypertrophic obstructive cardiomyopathy

Background

Non-cardiac surgery for hypertrophic obstructive cardiomyopathy (HOCM) is considered to require meticulous perioperative care. β-blockers are considered the first-line drugs for patients with HOCM, and they play a key role in preventing cardiovascular complications in perioperative care. The bisoprolol transdermal patch has recently become available in Japan, and it is useful for patients who are unable to take oral medication during perioperative care. The aim of this case series was to assess the hemodynamic features of patients with HOCM who used the bisoprolol transdermal patch during perioperative care for non-cardiac surgery.

Methods

Between August 2016 and August 2018, we retrospectively analyzed 10 consecutive cases of HOCM with the patients using the bisoprolol transdermal patch during perioperative care. Hemodynamic and echocardiographic features were evaluated before and after patients were switched from oral bisoprolol to transdermal patch therapy or started transdermal patch therapy as a new β-blocker medication. In addition, cardiovascular complications (all-cause death, cardiac death, heart failure, ventricular tachycardia, and ventricular fibrillation) during the perioperative period were evaluated.

Results

There was no significant change in the patients’ heart rate, blood pressure, ejection fraction, and pressure gradient in the left ventricle after switching from oral bisoprolol to the transdermal patch therapy. On the other hand, patients who started using the bisoprolol transdermal patch as a new ß-blocker medication tended to have a decreased heart rate and pressure gradient thereafter, but there was no significant difference in blood pressure or ejection fraction. No cardiovascular complications occurred during the perioperative period.

Conclusions

We described the utilization of the bisoprolol transdermal patch during perioperative care for non-cardiac surgery in patients with HOCM. We determined that the hemodynamic features of these patients did not change significantly after switching to patch therapy. Further, initiation of the bisoprolol transdermal patch as a new ß-blocker medication sufficiently tended to decrease the pressure gradient. This unique approach can be an alternate treatment option for HOCM.

Trial registration

The registry was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000036703). The date of registration was 10/5/2019 and it was “Retrospectively registered”.

Photoinduced Electron Transfer-Promoted Reactions Using Exciplex-Type Organic Photoredox Catalyst Directly Linking Donor and Acceptor Arenes

Directly linked donor and acceptor arenes, such as phenanthrene/naphthalene/biphenyl and 1,3-dicyanobenzene were found to work as photoredox catalysts in the photoreactions of indene, 2,3-dimethyl-2-butene, and 4-methoxyphenylacetic acid. The new stable organic photocatalyst forms an intramolecular exciplex (excited complex) when irradiated in a polar solvent and shows redox catalyst activity, even at low concentrations. To the best of our knowledge, this is the first example of an intramolecular exciplex working as a redox catalyst.

Massive mass embolism detected by transesophageal echocardiography in bone cement implantation syndrome: a case report

Bone cement implantation syndrome (BCIS) is a known complication in patients undergoing cemented orthopedic surgeries; however, the etiology and pathophysiology of BCIS are not fully understood. We report the case of a patient who developed pulseless electrical activity (PEA) due to BCIS after cemented femoral head replacement. Transesophageal echocardiography (TEE) during PEA revealed a massive embolus extending from the main pulmonary artery to the inferior vena cava. Of note, this embolus disappeared completely and rapidly after return of spontaneous circulation. TEE proved to be useful in the diagnosis and management of this case of PEA.

Identification and characterization of a novel adenomatous polyposis coli mutation in adult pancreatoblastoma

During next generation sequencing (NGS) analysis, many missense mutations were found in a well-known oncogene, many of which were variant of uncertain significance mutations. We recently treated an adult patient with pancreatoblastoma by chemotherapy. Using an NGS cancer panel, we found a previously unreported missense mutation in the 1835 codon of the adenomatous polyposis coli (APC) gene. We also found a heterogeneous mutation in the 1835 codon of the APC gene in the patient's germline by Sanger sequencing. Although this patient did not have a history of familial adenomatous polyposis, functional analysis suggested the R1835G mutant APC showed attenuated repression of Wnt/β-catenin signaling activity. This is the first report showing a novel APC missense mutation involved in the onset of adult pancreatoblastoma.

Observation and determination of periodontal tissue profile using optical coherence tomography

BACKGROUND AND OBJECTIVE

Diagnosis is a crucial step in periodontal treatment. The aim of this study was to evaluate the effectiveness of optical coherence tomography (OCT) for observation and determination of periodontal tissue profiles in vivo.

MATERIAL AND METHODS

In experiment 1, refractive indices of purified water, porcine gingiva and human gingiva at 1330 nm were determined for the analysis of OCT images of periodontal tissues. In experiment 2, OCT examination was performed in the midlabial apico-coronal plane of mandibular anteriors in 30 Asian volunteers with healthy gingiva. Sulcus depth was measured on intra-oral photographs taken during probing. In the OCT images, the gingival, epithelial and connective tissue thickness, and the position of alveolar bone crest were determined and finally, the biologic width was measured.

RESULTS

Refractive indices of purified water, porcine gingiva and human gingiva were 1.335, 1.393 and 1.397, respectively. Cross-sectional images of gingival epithelium, connective tissue and alveolar bone were depicted in real-time. The sulcular and junctional epithelium could be visualized occasionally. Laser penetration and reflection were limited to a certain depth with an approximate maximal imaging depth capability of 1.5 mm and OCT images of the periodontal structure were not clear in some cases. The average maximal thickness of gingiva and epithelium and biologic width at the mandibular anteriors were 1.06 ± 0.21, 0.49 ± 0.15 and 2.09 ± 0.60 mm, respectively.

CONCLUSION

OCT has promise for non-invasive observation of the periodontal tissue profile in detail and measurement of internal periodontal structures including biologic width in the anterior region.