Norwood Operation with Right Ventricular-Pulmonary Artery Shunt Versus Comprehensive Stage II After Bilateral Pulmonary Artery Banding Palliation

As a strategy for the primary Norwood operation, the right ventricular-pulmonary artery shunt is associated with satisfactory early outcome. However, use of this shunt after bilateral pulmonary artery banding remains controversial. This study compared the operative outcomes and late hemodynamics in patients who underwent the Norwood operation, preceded by bilateral pulmonary artery banding, with a right ventricular-pulmonary artery shunt or with bidirectional Glenn anastomosis (comprehensive stage II strategy). We retrospectively reviewed 38 patients who underwent the Norwood operation preceded by bilateral pulmonary artery banding between 2004 and 2017. Of these, 17 underwent the Norwood operation with a right ventricular-pulmonary artery shunt (Group S), whereas 21 underwent the comprehensive stage II strategy (Group G). 5 years after the Norwood operation, 10 (60%) and 17 (81%) patients in Group S and Group G, respectively, underwent the Fontan procedure. Group S showed significantly lower pressure in the superior vena cava after bidirectional Glenn anastomosis than Group G (13 ± 2 mmHg vs. 18 ± 3 mmHg; p < 0.01), but pressures were similar after the Fontan procedure. The right ventricular end-diastolic volume at 1 year post-Fontan procedure was significantly higher in Group S than in Group G (142 ± 41% vs. 91 ± 28%; p < 0.01). In terms of early outcomes, the Norwood operation with a right ventricular-pulmonary artery shunt enabled low pressure in the superior vena cava, but in the long term, this shunt adversely influenced the right ventricular volume.

Impact of the Rudimentary Chamber on Outcomes in Fontan Patients

Background: We sought to evaluate the influence of the rudimentary ventricle on long-term outcomes after the Fontan operation, focusing on exercise capacity and cardiac performance. Methods: Between 1995 and 2021, 290 patients underwent a total cavopulmonary connection. "Two-ventricle" Fontan circulation was defined as a rudimentary ventricle >30% of the dominant ventricle or >50% of its predicted normal value. This cohort was compared with patients with single-ventricle Fontan circulation. The primary endpoint was Fontan failure, and the secondary endpoints were VO2 and cardiac catheterization data at ten years postoperatively. Results: The median follow-up after the Fontan operation was 7.9 years (interquartile range: 1.9-13.9). No significant difference was found in Fontan failure-free survival between the "two-ventricle" Fontan circulation group and the single-ventricle Fontan circulation group (83/91, 93% vs 156/199, 78%), respectively at 20 years; P = .11). No significant difference was found in VO2 or cardiac performance except cardiac index, with 2.9 (2.3-4.8) versus 2.5 (2.3-4.3) L/min/m2 (P = .047). Fifty-one patients in the "two-ventricle" Fontan circulation group were followed up for over ten years after the Fontan operation. In the subgroup analysis of this cohort, the rudimentary ventricular end-diastolic volume/dominant ventricular end-diastolic volume ratio showed a significant positive correlation with dominant ventricular end-diastolic pressure (r = 0.58 [95% CI 0.35-0.74], P = .002) and a significant negative correlation with VO2 (r = -0.61 [95% CI -0.80 to -0.28], P = .001). Conclusions: The rudimentary ventricle was not significantly associated with any clinical disadvantages regarding Fontan failure. However, a large rudimentary ventricle was significantly associated with higher end-diastolic pressure and lower exercise capacity.

Pulmonary artery coarctation repair in univentricular heart: indications and optimal timing

BACKGROUND

To analyse surgical outcomes of pulmonary artery coarctation in univentricular hearts, focusing on surgical indications and optimal timing.

METHODS

We retrospectively reviewed 49 patients with pulmonary artery coarctation in univentricular hearts treated at our institution between 1993 and 2022. Twenty-eight patients were diagnosed before first-stage palliation. Of these, 14 underwent systemic-pulmonary shunt only as first-stage palliation (Group 1), and 14 underwent systemic-pulmonary shunt plus surgical pulmonary artery plasty as first-stage palliation (Group 2). Twenty-one patients diagnosed after first-stage palliation underwent surgical pulmonary artery plasty at the time of bidirectional Glenn procedure (Group 3).

RESULTS

Follow-up period after initial palliation was 6±8 years. The Fontan procedure was successful in 35 patients (71%) aged 28±26 months (range 18-139). Freedom from interstage death (Group 1, 53%; Group 2, 85%; Group 3, 93%) and interstage reintervention (Group 1, 50%; Group 2, 75%; Group 3, 73%) rates were significantly lower in Group 1 (p = 0.01). Five and four patients in Group 1 and Group 3, respectively, needed additional shunts before the bidirectional Glenn procedure. In Group 1, one patient with a non-confluent pulmonary artery achieved hemi-lung Fontan circulation. In Group 2, one patient suffering with a non-confluent pulmonary artery could not achieve Fontan circulation, whereas another patient with pulmonary venous obstruction achieved hemi-lung Fontan circulation.

CONCLUSIONS

Surgical pulmonary artery plasty performed at first-stage palliation improved outcomes of pulmonary artery coarctation in univentricular hearts, particularly when pulmonary artery coarctation had already progressed during the neonatal period or early infancy.

Impact of Optimal Fenestration Size on Outcomes of High-Risk Fontan Patients

BACKGROUND

We aimed to analyze mid-term outcomes of the fenestrated Fontan procedure, focusing on the fenestration size.

METHODS

We retrospectively reviewed the outcomes of the fenestrated Fontan procedure. Among 165 patients who underwent the Fontan procedure from 2011 to 2021, fenestration was created in 27 patients with the highest risks, including those with hypoplastic left heart syndrome, hypoplastic pulmonary arteries, heterotaxy syndrome with high pulmonary vascular resistance, and pulmonary arterial pressure >15 mm Hg. The patients underwent the procedure at a median age of three years (body weight, 11.4 kg; body surface area, 0.54 m2). Fenestration sizes were 3.5 to 5 mm.

RESULTS

Spontaneous fenestration closure occurred within one year postoperatively in nine patients. Among them, three experienced Fontan failure, necessitating refenestration. Although fenestration size did not differ, the size corrected by body surface area at the time of surgery was smaller in patients with fenestration closure (6.4 mm/m2 vs 8.3 mm/m2, P < .05). Patients with a fenestration <7 mm/m2 were more likely to have fenestration closure within one year postoperatively, and those with a fenestration >9 mm/m2 were more likely to have severe desaturation and require home oxygen therapy following discharge.

CONCLUSIONS

Spontaneous fenestration closure affected the frequency of Fontan complications. A very small fenestration size corrected by body surface area was a significant risk factor for spontaneous closure. Conversely, a very large fenestration size corrected by body surface area resulted in severe desaturation. The optimal fenestration size to prevent early spontaneous closure and severe desaturation is approximately 8 mm/m2.

Congenital Non-Confluent Pulmonary Artery Sourced from Bilateral Arterial Ducts: A Rare Anomaly

This study aimed to identify the influence of the non-confluent pulmonary artery originating from the bilateral arterial ducts (AD) on the outcomes of the Fontan circulation. We retrospectively reviewed the records of nine patients with bilateral AD and a non-confluent pulmonary artery in a single ventricle at our institution between 1993 and 2023. Three patients showed maintained AD or underwent a systemic-pulmonary shunt for stenotic AD, followed by the Glenn procedure. Four patients underwent systemic-pulmonary shunt with angioplasty as the first palliation, followed by the Glenn procedure. Two patients underwent systemic-pulmonary shunt or AD stenting as the first palliation and systemic-pulmonary shunt with angioplasty as the second palliation. There were no cases of interstage mortality. Pulmonary arteries grew and achieved a good balance (pre-Fontan pulmonary artery index [PAI], 164 ± 27 mm2/m2; right/left PAI ratio, 1.06 ± 0.23). All patients underwent the Fontan procedure (median, 3.5 years; range, 2.3-6.4 years) and were followed up for 7.8 years (range, 0.1-16.4 years) after the procedure. One patient required hospitalization for heart failure at 1.8 years, and three patients required catheter intervention for pulmonary stenosis within 2 months after the Fontan procedure. Non-confluent pulmonary arteries originating from the bilateral AD do not preclude Fontan completion and good Fontan outcomes by restoring balance to pulmonary blood flow. Due to the limited sample size in this study, additional research is imperative to delve deeper into our findings and enhance understanding of the most effective surgical approach for this disease.

Outlet Ventricular Septal Defect: Impact of Surgery on the Late Aortic and Pulmonary Valve Functions

This study retrospectively evaluated long-term post-operative aortic and pulmonary valve functions in outlet ventricular septal defects. We evaluated aortic regurgitation and pulmonary regurgitation using pre- and post-operative echocardiograms. Overall, 158 patients who underwent intracardiac repair due to outlet ventricular septal defects with aortic valve deformity or congestive heart failure were included. The median follow-up period was 7 years (interquartile range: 0-17 years), without deaths or pacemaker implantations. The age, weight, ventricular septal defect size, and mild aortic regurgitation at surgery were factors associated with post-operative residual aortic regurgitation. Mild pulmonary regurgitation was observed in 12%, 30%, and 40% of patients 5, 10, and 15 years after surgery, respectively. There were no significant differences in age and weight at which surgery was performed between patients with mild pulmonary regurgitation and those with less than mild pulmonary regurgitation. However, the number of sutures across the pulmonary valve was associated with post-operative pulmonary regurgitation (P < 0.01). As some patients with mild pre-operative aortic regurgitation may not improve even after surgery, early surgical intervention is necessary when aortic regurgitation appears. Some patients may develop post-operative pulmonary regurgitation in the long term, suggesting the need for careful follow-up.

Congenital Mitral Regurgitation Repair Based on Carpentier's Classification: Long-Term Outcomes

BACKGROUND

There are few reports of the outcomes of standardized surgical management addressing the etiologic and morphologic aspects of mitral valve malformation according to Carpentier's classification. This study aimed to evaluate the long-term outcomes of mitral valve repair in children according to Carpentier's classification.

METHODS

Patients who underwent mitral valve repair at our institution between 2000 and 2021 were retrospectively reviewed. Preoperative data, surgical techniques, and outcomes were analyzed according to Carpentier's classification. The proportion of patients free of mitral valve replacement and reoperation was estimated using Kaplan-Meier analysis.

RESULTS

Twenty-three patients (median operative age, four months) were followed up for 10 (range, 2-21) years. Preoperative mitral regurgitation was severe in 12 patients and moderate in 11 patients. Eight, five, seven, and three patients had Carpentier's type 1, 2, 3, and 4 lesions, respectively. Ventricular septal defect (N = 9) and double outlet of the great arteries from the right ventricle (N = 3) were the most commonly associated cardiac malformations. There were no cases of operative mortality or deaths during the follow-up. The overall five-year rate of freedom from mitral valve replacement was 91%, whereas the five-year rates of freedom from reoperation were 74%, 80%, 71%, and 67% in type 1, 2, 3, and 4 lesions, respectively. Postoperative mitral regurgitation at the last follow-up was moderate in three patients and less than mild in 20 patients.

CONCLUSIONS

Current surgical management of congenital mitral regurgitation is generally considered adequate; however, more complicated cases required a combination of various surgical techniques.

Aortic-to-Right Ventricle Shunting for Rare Cardiovascular Conditions

Pulmonary atresia with hypoplastic right ventricle and ventricular septal defect with right ventricle-dependent coronary circulation are very rare congenital heart anomalies. This report describes the case of a patient in whom aortic-right ventricle shunting was surgically established with a satisfactory postoperative course. Aortic-right ventricle shunting can enhance oxygenation of the sinusoidal communication and reduce the incidence of myocardial ischemia without influencing the left ventricular volume load through the ventricular septal defect despite preservation of the septal defect.

Efficacy and safety of balloon pulmonary angioplasty for patients with chronic thromboembolic pulmonary hypertension comorbid to chronic obstructive pulmonary disease

Background

Balloon pulmonary angioplasty (BPA) would be promising treatment option for non-operable chronic thromboembolic pulmonary hypertension (CTEPH). However, BPA for CTEPH with Chronic obstructive pulmonary disease (COPD) might exacerbate ventilation perfusion mismatch. The aim is to evaluate the efficacy and safety of BPA for CTEPH with moderate or severe COPD.

Method

Data from 149 CTEPH patients were collected retrospectively who underwent BPA from March 2011 to June 2021. Patients were divided according to the comorbidity of COPD: a COPD group (defined as forced expiratory volume in one second (FEV1.0) / forced vital capacity (FVC)&lt;70% and FEV1.0&lt;80% predicted [n=32]) or a non-COPD group [n=101]. Mild COPD patients (n=16) were excluded. Hemodynamics and respiratory parameters were compared.

Results

Hemodynamics improved similarly in both group (percent decrease of pulmonary vascular resistance; −61.1±12.3% in a COPD group, −65.8±11.1% in a non-COPD group, p=N.S). Patients in a COPD group showed improved respiratory function and oxygenation with FEV1.0% from 61.8±7.0% to 66.5±10.2% (p=0.02), and partial pressure of arterial oxygen from 60.9±10.6mmHg to 69.3±13.6mmHg (p&lt;0.01). Higher vital capacity (r2=0.123, p=0.024), higher diffusing capacity for lung carbon monoxide (r2=0.308, p=0.028) at baseline were correlated with larger improvement of oxygenation after BPA in multivariate linear analyses. Lung injury per session was 1.6% in a COPD group.

Conclusion

The efficacy and safety of BPA for non-operable CTEPH with COPD were equivalent to those of patients without COPD. Oxygenation and FEV1.0% also improved in COPD patients. BPA might be considered even though patients comorbid COPD.

Funding Acknowledgement

Type of funding sources: None.

Bilateral pulmonary artery banding for transposition of the great arteries complex with coarctation

Surgical approaches for transposition of the great arteries with aortic arch obstruction include primary repair and two-stage repair. However, neither approach provides a satisfactory outcome. We report a case of patient who underwent two-stage repair, wherein arterial switch operation combined with aortic arch reconstruction was preceded by bilateral pulmonary artery banding; this yielded good outcomes. This approach safely avoids primary repair in the neonatal period and allows for the opportunity to evaluate right ventricle outlet tract stenosis before the definitive repair.

Anticoagulation Therapy After the Fontan Procedure

The optimum postoperative anticoagulation therapy type and duration after the Fontan procedure remains unclear. This study aimed to evaluate whether our approach of administering only oral antiplatelets without warfarin due to serious bleeding complication risks in children is reasonable. We retrospectively reviewed the data of 249 patients who underwent the Fontan procedure. Total cavopulmonary connection with extracardiac conduit was performed in 230 patients (92%), the lateral tunnel Fontan procedure was performed in 18 patients (8%), and intraatrial conduit Fontan procedure was performed in one patient. Aspirin administration (initial dose: 5 mg/kg/day) was continued in all patients. Only 29 patients (11%) received combined administration of aspirin and warfarin for various reasons, and warfarin was discontinued in 20 (71%) of these within a median of 16 months postoperatively. Sixteen patients at high risk of thromboembolism were started on warfarin. Hospital mortality was 0%, with no thromboembolic or bleeding event-related early death. Nine late deaths, not associated with bleeding nor thromboembolism, occurred except one resulting from cardiac infarction 1.9 years after the procedure. During hospitalization, five patients experienced graft thromboembolism, two of which underwent graft exchange, and the others were started on warfarin. In the late phase (3.1 ± 6.6 years), cerebral infarction (n = 3), peripheral pulmonary artery occlusion (n = 2), gastrointestinal bleeding (n = 5), and respiratory hemorrhage (n = 4) occurred. Eight of nine patients with bleeding events received only aspirin. Thromboembolic events occurred in six patients within the first year after the procedure. Bleeding events occurred at 8 ± 5.5 years after the procedure. Expected freedom from a thromboembolic event was 99.8% at 1 year and 93.4% at 20 years. Expected freedom from a bleeding event was 100% at 1 year and 88.4% at 20 years. In children at low risk of thromboembolism after the Fontan procedure, continuous administration of an oral antiplatelet agent alone without warfarin seems to represent a reasonable prophylactic approach.

Management of neonatal cardiac rhabdomyoma obstructing the aortic valve

Rhabdomyomas associated with tuberous sclerosis are common cardiac tumors in children, and no surgical intervention is needed in most cases. However, when the tumor causes left ventricular outlet tract obstruction (LVOTO), immediate surgical intervention is indicated. Here, we report a newborn who was diagnosed antenatally with multiple cardiac rhabdomyomas, one of which blocked the aortic valve during systole. The tumor was resected early in the postnatal period with excellent outcomes. Until surgery, we maintained ductus arteriosus patency and systemic circulation using prostaglandin E1, which helped to reduce the risk of sudden death due to LVOTO. Postoperative two-dimensional echocardiography at discharge showed that surgery was effective in resolving LVOTO.

Reconstruction in left main coronary artery atresia with bypass graft obstruction

Paediatric coronary artery bypass surgery with internal thoracic artery grafting is the optimal choice for left main coronary artery atresia; we report successful reconstruction in a patient with bypass graft obstruction. The pulmonary trunk was transected to expose the left main coronary stem, which was opened beyond the obstruction and the incision extended through the left main coronary artery to the circumflex bifurcation and left anterior descending artery. A funnel-shaped coronary ostium was created with a glutaraldehyde-treated autologous pericardium onlay patch. Surgical reconstruction is a good alternative for left main coronary artery atresia with graft obstruction and preserves the remaining internal thoracic artery for future use.

Precise Measurement of Differential Cross Sections of the Σ^{-}p→Λn Reaction in Momentum Range 470-650 MeV/c

The differential cross sections of the Σ^{-}p→Λn reaction were measured accurately for the Σ^{-} momentum (p_{Σ}) ranging from 470 to 650  MeV/c at the J-PARC Hadron Experimental Facility. Precise angular information about the Σ^{-}p→Λn reaction was obtained for the first time by detecting approximately 100 reaction events at each angular step of Δcosθ=0.1. The obtained differential cross sections show a slightly forward-peaking structure in the measured momentum regions. The cross sections integrated for -0.7≤cosθ≤1.0 were obtained as 22.5±0.68 [statistical error(stat.)] ±0.65 [systematic error(syst.)] mb and 15.8±0.83(stat)±0.52(syst)  mb for 470<p_{Σ}(MeV/c)<550 and 550<p_{Σ}(MeV/c)<650, respectively. These results show a drastic improvement compared with past measurements of the hyperon-proton scattering experiments. They will play essential roles in updating the theoretical models of the baryon-baryon interactions.

X ray spectroscopy on 𝚵− atoms (J-PARC E03, E07 and future)

X-ray spectroscopy of hadronic atoms is a powerful method to study strong interaction between hadrons and nuclei. At J-PARC, we have conducted two experiments, J-PARC E07 and E03, for hadronic atoms with a doubly strange hyperon, Ξ−, aiming at the world-first detection of their X-rays. The first measurement is performed as a byproduct of J-PARC E07 experiment with the hybrid emulsion technique. The second one, J-PARC E03, is a dedicated experiment for detection of Ξ− Fe atom X rays. The preliminary results and the present status of E07 and E03 are shown in this article. Future prospects of Ξ−-atomic X-ray spectroscopy are also discussed. A new measurement has been proposed for detecting Ξ− C atom X rays, where a novel Ξ− tracking method will be applied to realize an improved signal to noise ratio.

J-PARC hadron experimental facility extension project *

The J-PARC Hadron Experimental Facility was constructed with an aim to explore the origin and evolution of matter in the universe through experiments with intense particle beams. In the past decade, many results from particle and nuclear physics experiments have been obtained at the present facility. To expand the physics programs to as yet unexplored regions, the extension project of the Hadron Experimental Facility has been extensively discussed. This contribution presents the physics of the extension of the Hadron Experimental Facility to resolve issues related to strangeness nuclear physics, hadron physics, and flavor physics.

High resolution spectroscopy of the “ΣN cusp” by using the d(K−, π−) reaction

We present a new proposal, J-PARC E90, to measure a missing-mass spectrum near the ΣN threshold for the d(K−, π−) reactions at 1.4 GeV/c. While many previous experiments support apparent enhancement near the ΣN thresh-old, the dynamical origin of this so-called “ΣN cusp” remains yet unsolved. The enhancement suggests either a cusp structure or a weakly bound state. One of the keys to making it clear is improving the missing-mass resolution and statistics. Our new experiment can achieve the missing-mass resolution of 0.4 MeV in σ using the K1.8 beam line and S-2S spectrometers at J-PARC. Further-more, we can suppress quasi-free background processes with the time projection chamber (HypTPC), which operated nicely for the H-dibaryon search experi-ment (J-PARC E42). The J-PARC E90 aims to extract the scattering length of the ΣN system with isospin T = 1/2 and spin-triplet channels.

Results of analysis of Σ+p scattering events in J-PARC E40 experiment: differential cross sections and phase shifts of 3S1 and 1P1 states

We performed a novel Σ+p scattering experiment at the J-PARC Hadron Experimental Facility. Approximately 2400 Σ+p scattering events were identified by a kinematical consistency check for the recoil proton. The differential cross sections of the Σ+p elastic scattering were derived with better precision than in previous experiments. By exploiting high-quality differential cross section data and the simple representation of Σ+p interaction in the SU(3) flavor symmetry, we performed a phase-shift analysis on hyperon-nucleon scattering data for the first time. The absolute value of the phase shift of the 3S1 channel, where a large repulsive force was predicted due to the Pauli exclusive effect between quarks, was evaluated. These results indicate that the interaction of the 3S1 channel in the Σ+p channel is moderately repulsive, as the Nijmegen extended-soft-core models predicted.

Λ polarization measurement of the π−p → K0Λ reaction in J-PARC E40 experiment

We performed the J-PARC E40 experiment to measure the Σp scattering cross sections from 2018 to 2020. Together with the π−p → K+Σ− data, the π−p → K0Λ data were accumulated as a byproduct. The analysis confirmed that Λ could be identified with an S/N ratio of ∼ 2.67. The polarization of Λ(PΛ) was preliminarily derived as 1.009 ± 0.049 for the K0 angular range of 0.7 < cos θK0, CM < 0.8. It is more accurate than the past data [1]. The high polarization enables us to measure not only the differential cross section but also spin observables of the Λp scattering in the future J-PARC experiment.

Preparation status of missing-mass spectroscopy for 𝚵 hypernuclei with S-2S magnetic spectrometer

J-PARC E70 experiment measures the missing-mass of Ξ hypernuclei (12ΞBe) in Hadron Experimental Facility at J-PARC. We aim to reach the best missing-mass resolution of 2 MeV/c2 in FWHM with a new magnetic spectrometer S-2S. The high-resolution spectroscopy of Ξ hypernuclei will play an important role to understand the unknown ΞN interaction. The experiment will start at the beginning of 2023. This article presents the preparation status.

Strangeness physics programs by S-2S at J-PARC

In the K1.8 beam-line at Hadron Experimental Facility of J-PARC, a new magnetic spectrometer S-2S is being installed. S-2S was designed to achieve a high momentum resolution of Δp/p = 6 × 10−4 in FWHM. Several strangeness-physics programs which require the high resolution will be realized by S-2S. The present article introduces J-PARC E70 (missing-mass spectroscopy of Ξ12Be) and E94 (missing-mass spectroscopy of Λ7Li, Λ10B, and Λ12C) experiments.

High resolution spectroscopy of 𝚵 hypernuclei with active fiber target

We are planning to carry out a high-resolution spectroscopy of Ξ hypernucleus at the J-PARC K1.8 beamline, which provides a highintensity K− beam (J-PARC E70 experiment). The high-resolution spectroscopy aims to be realized by introducing a new magnetic spectrometer S-2S and an active fiber target AFT. In this article, the role of the AFT in this experiment and its development status are described.

Recent progress and future prospects of hyperon nucleon scattering experiment

A new hyperon-proton scattering experiment, dubbed J-PARC E40, was performed to measure differential cross sections of the Σ+p, Σ−p elastic scatterings and the Σ−p → Λn scattering by identifying a lot of Σ particles in the momentum ranging from 0.4 to 0.8 GeV/c produced by the π±p → K+Σ± reactions. We successfully measured the differential cross sections of these three channels with a drastically improved accuracy with a fine angular step. These new data will become important experimental constraints to improve the theories of the two-body baryon-baryon interactions. Following this success, we proposed a new experiment to measure the differential cross sections and spin observables by using a highly polarized Λ beam for providing quantitative information on the ΛN interaction. The results of three Σp channels and future prospects of the Λp scattering experiment are described.

OUP accepted manuscript

Association between hypoplastic left heart syndrome and valvular pulmonary stenosis is very rare. Severity of valvular pulmonary stenosis in this setting limits management options. Consequently, patients with this condition are considered poor candidates for Norwood stage one reconstruction. Herein, we describe a newborn with hypoplastic left heart syndrome and significantly dysplastic pulmonary valve who successfully underwent the Norwood procedure with neoaortic valve reconstruction. Therefore, the Norwood procedure with neoaortic valve reconstruction might be an option for this difficult condition.

Observation of Coulomb-Assisted Nuclear Bound State of Ξ^{-}-^{14}N System

In an emulsion-counter hybrid experiment performed at J-PARC, a Ξ^{-} absorption event was observed which decayed into twin single-Λ hypernuclei. Kinematic calculations enabled a unique identification of the reaction process as Ξ^{-}+^{14}N→_{Λ}^{10}Be+_{Λ}^{5}He. For the binding energy of the Ξ^{-} hyperon in the Ξ^{-}-^{14}N system a value of 1.27±0.21  MeV was deduced. The energy level of Ξ^{-} is likely a nuclear 1p state which indicates a weak ΞN-ΛΛ coupling.

Microvasculopathy evaluated by dual-energy computed tomography in chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension

Background

It has been previously reported that poor subpleural perfusion (PSP) in dual-energy computed tomography (DE-CT) might suggest the microvasculopathy in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, it remains unclear whether pathological findings of microvasculopathy in CTEPH and pulmonary arterial hypertension (PAH) are equivalent. The aim is to evaluate the microvasculopathy in CTEPH and PAH by using clinical parameters and DE-CT.

Methods

We retrospectively reviewed PSP (defined as subpleural spaces either not or minimally perfused in all segments) of consecutive treatment-naïve 89 CTEPH patients and 20 PAH patients who underwent DECT from Feb. 2015 to Dec. 2019.

We also evaluated hemodynamic parameters and DE-CT parameters including quantitative evaluation of pulmonary blood volume (PBV) which was calculated as the average of entire lung iodine density.

Results

PSP was observed in 49.4% of patients in CTEPH group versus 5.0% in PAH group (p&lt;0.01).

There were no significant differences in hemodynamics and lung PBV between CTEPH group and PAH group (mean pulmonary arterial pressure; 36.4±10.4mmHg vs 38.3±8.5mmHg p=0.464, pulmonary vascular resistance; 700±388dyne*sec/cm5 vs 805±440 dyne*sec/cm5 p=0.288, lung PBV; 24.9±6.4 Hounsfield Unit vs 22.0±6.6 Hounsfield Unit p=0.06, respectively), however diffusing capacity for carbon monoxide (%DLCO/VA) was significantly lower (69.5±16.8% vs 45.7±23.7% p&lt;0.01) in PAH group.

Conclusion

PSP in DE-CT, which was observed more frequently in patients with CTEPH, might suggest the different mechanism of microvasculopathy from PAH in patients with CTEPH. Microvasculopathy in CTEPH would be diffuse very distal thrombosis. DE-CT is effective modality to detect microvasculopathy of diffuse distal thrombosis in patients with CTEPH.

DECT, Poor subpleural perfusion

Funding Acknowledgement

Type of funding source: None

Efficacy of interventional treatment for patients with chronic thromboembolic pulmonary hypertension with microvasculopathy

Background

The existence of microvasculopathy in chronic thromboembolic pulmonary hypertension (CTEPH) had been suggested. However, the impact of microvasculopathy for pathophysiology had been unknown. Recently dual-energy computed tomography (DECT) can produce a sensitive iodine distribution map in lung fields to quantify lung perfusion, which may indicate the existence of microvasculopathy according to poor subpleural perfusion.

This study aimed to examine the therapeutic efficacy of interventional treatment (pulmonary endarterectomy or/and balloon pulmonary angioplasty) in CTEPH with microvasculopathy.

Methods

We retrospectively reviewed poor subpleural perfusion (defined as subpleural spaces either not or minimally perfused in all segments) and hemodynamics of 70 consecutive CTEPH patients who underwent DECT before and after interventional therapy from January 2014 to January 2020.

Patients were divided according to poor subpleural perfusion in DECT images before treatment: a microvasculopathy group (MV group, n=37) or a non-microvasculopathy group (Non-MV group, n=33).

We evaluated clinical parameters as WHO functional class (WHO-Fc), 6-min walk distance, respiratory function test, cardiopulmonary exercise test, hemodynamic parameters, and DECT parameters at baseline and after the treatments. DECT parameters as quantitative evaluation of pulmonary blood volume (PBV) calculated as the average of entire lung iodine density.

Results

After interventional treatments, WHO-Fc improved in 33 patients in MV group, and 27 patients in Non-MV group (p=0.50).

In MV group, baseline mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR) and VE/VCO2 slope were higher (38.3±9.3 vs. 33.2±10.8 mmHg p=0.04, 818±394 vs. 539±289 dyne*sec/cm5 p&lt;0.01 and 43.7±11.3 vs. 35.2±6.9 p&lt;0.01, respectively) and PBV were lower (43.7±11.3 vs. 35.2±6.9 Hounsfield Unit p&lt;0.01) After the treatments, mPAP, PVR, VE/VCO2 slope and PBV showed almost equivalent between the groups (19.5±4.1 vs. 20.6±5.1 mmHg p=0.35, 272±111 vs 251±109 dyne*sec/cm5 p=0.42, 29.2±6.3 vs. 26.0±6.1 p=0.06 and 27.1±6.6 vs. 29.6±6.6 Hounsfield Unit p=0.13).

Diffusing capacity for carbon monoxide (%DLCO/VA) did not improve after treatment in both groups (MV group: 59.5±13.1 to 58.8±11.9% p=0.43. Non-MV group: 77.8±13.4% to 70.5±10.8% P&lt;0.01).

Conclusion

Hemodynamics, pulmonary perfusion, exercise capacities significantly improved after the treatments in spite of the existence or absence of microvasculopathy. However, DLCO which might indicate the existence of microvasculopathy did not improve. Interventional treatments could not improve microvasculopathy because of their limit of accessibilities.

Funding Acknowledgement

Type of funding source: None

P5344Paradigme shift to disequilibrium in the genesis of orthostatic intolerance in patients with chronic fatigue syndrome

Background

Chronic fatigue syndrome (CFS) characterized by severe disabling fatigue and prolonging post-exertional malaise. The dysfunction of the central nervous system associated with myalgic encephalomyelitis (ME) has been postulated as the main cause of CFS. Orthostatic intolerance (OI) causes a marked reduction in the activities of daily living and impairs the quality of life in patients with ME/CFS. OI has been surmised to be a cardiovascular symptom with cerebral hypo-perfusion and exaggerated sympathetic nervous activation.

Purpose

Postural instability or disequilibrium may be involved in the etiology of OI because postural stability is an essential element for static balance.

Methods

The study comprised 72 patients with ME/CFS (18 men and 54 women; mean age, 37±10 years), who underwent neurological examinations and the active 10-min standing test.

Results

Disequilibrium defined as instability on standing with their feet together and eyes shut, was detected in 23 (32%) patients while postural orthostatic tachycardia in 16 (22%). Compared with 49 patients without disequilibrium, patients with disequilibrium more prevalently failed to complete the 10-min standing test (74% vs. 4%, p<0.01) and body sway was significantly more prevalently observed during the test (100% vs. 12%, p<0.01). The performance status score was significantly higher in patients with disequilibrium than those without it (median: 7 vs. 5, p<0.01), suggesting more severely restricted activity of daily living in the former. The prevalence of postural orthostatic tachycardia during the standing test was comparable between the patients with disequilibrium (23%) and those without it (22%, p=1.00). The 19 (26%) patients who failed to complete the 10-min standing test had disequilibrium more prevalently than those who completed it (89% vs. 11%, p<0.01). Performance status score was significantly higher in patients who failed to complete it than those who completed it (median: 6 vs. 5, p<0.01), suggesting more severe restriction of activity of daily living in the former. Significantly higher rates of disequilibrium (89% vs. 11%, p<0.01), unstable standing on one leg (84% vs. 17%, p<0.01) as well as abnormal tandem gait (79% vs. 11%, p<0.01) were noted in patients who failed to complete it than those who completed it. Body sway during the standing test was significantly more prevalently observed in the patients who failed to complete it than those who completed it (89% vs. 23%, p<0.01). The prevalence of postural orthostatic tachycardia during the standing test was comparable between the patients who failed to complete it and those who completed it (21% vs. 23%, p=1.00). Among the patients who failed to complete it 8 had the previous study records which revealed that 6 of them had completed it 6–24 months before when all the 6 patients had had no disequilibrium.

Conclusion

Disequilibrium should be recognized as an important cause of OI in patients with ME/CFS.

P14.39 How far should it be removal beyond the Gd-enhanced edge in Glioblastoma cases? -Preoperative removal range identification using Methionine-PET and Thallium-SPECT fusion image

BACKGROUND

Mostly, the removal rate of glioblastoma has been discussed in the Gd enhanced area, but tumor cells are surely infiltrated beyond the Gd enhanced edge. Although Methionine-PET (MET) and Thallium-SPECT (Tl) are useful for preoperative tumor invasion range identification, they are off-label use in most countries, and their respective accumulation ranges do not match completely. In this study, Gd-MRI, MET, and Tl were performed, and the accumulation range was compared from the fusion images, and the prediction method of the tumor cell infiltration range was examined.

MATERIAL AND METHODS

The mean interval period between MET and Tl administration was 16.3 days in 21 cases of glioblastoma (12 male and 9 female, average age 59.1 ± 17.8 years). Fusion images were generated using iPlan Cranial 3.0.The MET-area, Tl-area, Overlap-area where MET and Tl overlap, and Accumulation-area where MET and Tl are maximally accumulated were measured in the same cross section as the Gd-enhanced maximum area (Gd-area, X cm2) in axial view. Each volume was also measured similarly.

RESULTS

Gd-area was correlated with all of MET-area, Tl-area, Overlap-area, and Accumulation-area (p ≦0.0001).Gd-volume (X’cm3) showed correlation with all of MET-volume, Tl-volume, Overlap-volume, and Accumulation-volume (p ≦0.0001). The linear approximation was calculated as follows. Overlap-area = 1.942X + 1.0208 (R = 0.937), Accumulation-area = 1.3299X + 6.098 (R = 0.889), Overlap-volume = 1.1539X ‘+ 7.0573 (R = 0.927), Accumulation-volume = 1.8668X ‘+30.06 (R = 0.893).

CONCLUSION

These linear approximations can be used to predict the tumor invasion range from the Gd-enhanced maximum area or Gd-enhanced volume without using off-label use drugs.

P14.08 Bevacizumab treatment for the lesion emerging after the radiotherapy for malignant glioma

BACKGROUND

Because blocking vascular endothelial growth factor from reaching leaky capillaries is a logical strategy for the treatment, we reasoned that bevacizumab might be an effective treatment on recurrent malignant glioma and radiation necrosis (RN). In this study, the authors examined to differentiate RN from recurrent malignant glioma, and evaluated the results of bevacizumab treatment in each diagnosis.

MATERIAL AND METHODS

Four patients of malignant glioma (2 glioblastomas and 2 anaplastic astrocytomas), which demonstrated symptomatic lesion after radiotherapy, were involved in this study. All four patients were treated with bevacizumab on a 10 mg/kg biweekly (one cycle), for a total dose of 30 mg/kg (3 cycles) or furthermore. RN was differentiated from local recurrence in all four patients on the basis of 11C-methionine positron emission tomography and/or clinical course. Clinical evaluation and MRI studies were obtained after bevacizumab treatment in all cases repeatedly as possible.

RESULTS

Two patients were diagnosed as RN, and another two patients as tumor recurrence. Of the two patients with RN, neurological dysfunction was distinctly alleviated after bevacizumab treatment. Other two patients with tumor recurrence demonstrated no remarkable improvement in neurological dysfunction after bevacizumab treatment. Of all the two patients with RN, post-treatment MRI performed after the bevacizumab therapy showed a significant reduction of the massive lesion.

CONCLUSION

We concluded that bevacizumab could control the symptomatic massive lesion occurring after radiotherapy, and it might be more effective with the patients of RN, than with those of recurrent tumor.

First Determination of the Level Structure of an sd-Shell Hypernucleus, _{Λ}^{19}F

We report on the first observation of γ rays emitted from an sd-shell hypernucleus, _{Λ}^{19}F. The energy spacing between the ground state doublet, 1/2^{+} and 3/2^{+} states, of _{Λ}^{19}F is determined to be 315.5±0.4(stat)_{-0.5}^{+0.6}(syst)  keV by measuring the γ-ray energy of the M1(3/2^{+}→1/2^{+}) transition. In addition, three γ-ray peaks are observed and assigned as E2(5/2^{+}→1/2^{+}), E1(1/2^{-}→1/2^{+}), and E1(1/2^{-}→3/2^{+}) transitions. The excitation energies of the 5/2^{+} and 1/2^{-} states are determined to be 895.2±0.3(stat)±0.5(syst) and 1265.6±1.2(stat)_{-0.5}^{+0.7}(syst)  keV, respectively. It is found that the ground state doublet spacing is well described by theoretical models based on existing s- and p-shell hypernuclear data.

One Label or Two? Linguistic Influences on the Similarity Judgment of Objects between English and Japanese Speakers

Recent findings have re-examined the linguistic influence on cognition and perception, while identifying evidence that supports the Whorfian hypothesis. We examine how English and Japanese speakers perceive similarity of pairs of objects, by using two sets of stimuli: one in which two distinct linguistic categories apply to respective object images in English, but only one linguistic category applies in Japanese; and another in which two distinct linguistic categories apply to respective object images in Japanese, but only one applies in English. We conducted four studies and tested different groups of participants in each of them. In Study 1, we asked participants to name the two objects before engaging in the similarity judgment task. Here, we expected a strong linguistic effect. In Study 2, we asked participants to engage in the same task without naming, where we assumed that the condition is close enough to our daily visual information processing where language is not necessarily prompted. We further explored whether the language still influences the similarity perception by asking participants to engage in the same task basing on the visual similarity (Study 3) and the functional similarity (Study 4). The results overall indicated that English and Japanese speakers perceived the two objects to be more similar when they were in the same linguistic categories than when they were in different linguistic categories in their respective languages. Implications for research testing the Whorfian hypothesis and the requirement for methodological development beyond behavioral measures are discussed.

The combined use of US and MR imaging for the diagnosis of masses in the parotid region

Purpose: To evaluate the usefulness of the combination of the two non-invasive modalities US and MR imaging to diagnose masses in the parotid region.

Material and Methods: The US and MR findings of 21 patients with parotid masses were analyzed retrospectively by two radiologists without any clinical or histopathological information. The specific points evaluated were location, shape, margin, internal architecture, and intensity level on both US and MR, posterior echo enhancement on US, and capsule-like lining of the tumor on MR.

Results: The findings concerning the shape and margin on US and MR were in fairly good agreement. Concerning the findings of the internal architecture, US could reveal the minute structures of the tumor while MR demonstrated differences in the signal intensities of histological tissue types of the various tumors. The posterior echo enhancement on US and the capsule-like lining on MR of the tumors were also useful for the diagnosis.

Conclusion: Our results suggest that the combination of US and MR is useful for examining soft tissue masses in the parotid region to make a more accurate diagnosis, and not just differentiate malignant lesions from those which are benign.

Interleukin-6, interleukin-6 receptor gene variant, small-vessel disease and incident dementia

BACKGROUND AND PURPOSE

Mixed neurogenerative and vascular dementia has emerged as the leading cause of dementia in the elderly. Inflammation is implicated in atherosclerosis, cerebral small-vessel disease (SVD) as well as cognitive impairment. However, longitudinal data on the predictive value of circulating inflammatory markers including gene variants and magnetic resonance imaging (MRI) findings in incident dementia are scarce. It was investigated whether circulating interleukin-6 (IL-6), C-reactive protein (CRP) and gene variants increase dementia risk.

METHODS

In a cohort of Japanese participants with vascular risk factors in an observational study from 2001, the association between baseline IL-6, CRP levels, gene variants [interleukin-6 receptor (IL-6R), rs2228145; IL-6, rs2097677; CRP, rs3093059] and incident all-cause dementia was evaluated. Baseline MRI was used to determine SVD (lacuna, white matter hyperintensities) and atrophy (medial-temporal lobe atrophy, bicaudate ratio). Cox proportional hazards analyses were performed for predictors of dementia, adjusting for age, sex, apolipoprotein Eε4, education, cerebrovascular events, vascular risk factors and MRI findings.

RESULTS

Of 803 subjects (mean 67.0 ± 8.5 years, males 59%), during a mean of 7.5 ± 3.2 years follow-up, 60 incident dementia patients (Alzheimer's disease 31; vascular dementia 17; mixed-type six; other six) were diagnosed. In multivariable analyses adjusted for age, sex, cerebrovascular events, MRI findings and IL-6R variant (rs2228145), IL-6 levels (relative risk 1.68, P = 0.048) or highest tertile (relative risk 2.38, P = 0.031) for all-cause dementia remained significant. Although subjects with rs2228145 carrier had significantly higher IL-6 levels, a significant association between rs2228145 and dementia was not observed. Conversely, CRP and remaining gene variants were not associated with dementia.

CONCLUSIONS

The deleterious effect of higher IL-6 on dementia remains consistent irrespective of conventional risk factors, MRI findings and IL-6R variant.

Serum high-molecular-weight adiponectin level and incident dementia in patients with vascular risk factors

BACKGROUND AND PURPOSE

The involvement of metabolic factors in the development of dementia has received much attention. However, previous studies have yielded conflicting results regarding how blood adipocytokine level impacts cognitive decline and dementia. This study aimed to clarify whether serum high-molecular-weight (HMW) adiponectin level is related to incident dementia.

METHODS

Data were from 466 patients (mean age 67.8 years, male 57%)--who had normal cognitive function and received brain magnetic resonance imaging--from amongst the 1106 patients in the Osaka Follow-up Study for Carotid Atherosclerosis, Part 2, a prospective cohort study of cardiovascular events and dementia amongst patients with vascular risk factors enrolled between 2001 and 2009. Baseline HMW adiponectin levels were measured using frozen serum. Dementia occurrence was examined in June 2013.

RESULTS

Serum HMW adiponectin level was 4.33 ± 2.95 μg/ml; the levels were lower in men than in women and negatively correlated with body mass index. During the follow-up period (median 6.9 years), 47 patients had incident dementia including Alzheimer's disease dementia (27), vascular dementia (13), mixed dementia (four), other dementia (three). Risks of dementia in patients with high versus low HMW adiponectin levels were almost identical (P = 0.689). No association was found between adiponectin levels and Alzheimer's disease dementia or vascular dementia in the whole group or amongst men and women separately.

CONCLUSIONS

This study demonstrated that serum HMW adiponectin level has little association with future dementia. Determination of metabolic factors involved in dementia requires evaluation of other biomarkers or parameters.