Risk factors of recurrent tricuspid regurgitation after valve repair with three-dimensional ring

Objective: The purpose of this study was to investigate the results of tricuspid valve (TV) repair with three-dimensional ring (3DR) and risk factors of recurrent tricuspid regurgitation (TR).Methods: We retrospectively investigated 171 patients who underwent TV repair with a 3DR for TR from 2007 to 2016 at our institution. The patients were divided into the non-Recurrence group (<2+ TR) and Recurrence group (≥2+ TR), and compared to identify the cause of recurrent TR. The mean follow-up period was 58±35 months.Results: The preoperative TR grade was 3.0±0.8. A total of 22 patients had at least ≥2+ TR in the follow-up period. Freedom from ≥2+ TR and re-operation at 5 years were 83.6±3.3% and 97.9±2.1%. Comparison of the non-Recurrence and Recurrence groups revealed significant differences in the preoperative TR grade (2.9±0.8 and 3.4±0.6, p=0.008), proportion of the patients with left ventricular ejection fraction (LVEF) <40% (9% and 32%, p=0.003) and right ventricular end-systolic dimension (RVDs, 22.8±7.1 mm and 31.1±12.3 mm, P=0.001). In the multivariate analysis, LVEF <40% (hazard ratio: 12.65, 95% confidence interval: 2.66–60.18; p=0.002) and RVDs (hazard ratio: 1.08, 95% confidence interval: 1.02–1.14; p=0.02) were identified as risk factors for recurrent TR.Conclusion: Our results of TV repair with 3DR were of satisfactory. However, patients with preoperative lower LVEF and larger RVDs were identified at risk of recurrent TR. This result suggests the limitation to use of 3DR alone for TV repair and need for additional procedure

Quality of life following aortic valve replacement in octogenarians

【Purpose】We aimed to evaluate the outcomes of and the quality of life (QOL) after conventional aortic valve replacement (AVR) amongst octogenarians.【Methods】We enrolled 48 patients aged ≥80 years who underwent conventional aortic valve replacement between May 1999 and November 2012. Patient conditions were assessed before surgery, at 6 and 12 months after surgery, and during the late period regarding the need for nursing care, degree of independent living, and living willingness.【Results】The follow-up rate was 100% with 45.6 ± 41.3 months follow-up. Two patients (4%) died during hospitalization and 11 (23%) died during the follow-up period. The 1-, 5-, and 10-year survival rates were 84.9, 76.9, and 39.6%, respectively. During the late period, of 35 surviving patients, 31 (88%) were living at home. The degree of independent living score decreased after surgery. However, scores of the need for nursing care and living willingness remained preoperative level.【Conclusions】QOL following conventional aortic valve replacement for elderly patients aged ≥80 years who showed independence in activities of daily living (ADL) before surgery were satisfactory. Therefore, aortic valve replacement could be a viable option for elderly patients aged ≥80 years after accounting for preoperative ADL levels

Characteristics and treatment strategies of mitral regurgitation associated with undifferentiated papillary muscle

Purpose: In this report we review our experience of operations on mitral regurgitation associated with abnormal papillary muscles/chordae tendineae of the mitral valves and discussed the clinical characteristics, operative findings, and treatment strategies. Methods: Undifferentiated papillary muscle was defined as a hypoplastic chordae tendineae with anomalous formation of papillary muscles attached to the mitral valves directly. Consecutive 87 patients undergoing surgery for mitral regurgitation at our institution were reviewed and 6 of them had undifferentiated papillary muscle. Results: The underlying mechanism of regurgitation was prolapse at the center of the anterior leaflet in 3 cases and tethering, a wide area of myxomatous degeneration, and annular dilatation in one case, respectively. Five patients underwent mitral valve plasty and 1 patient received replacement. Anomalous formation of chordae tendineae was corrected by resection and suture with transplantation at the tip of the leaflet to which abnormal chordae were attached in 2 cases, while resection and suture with chordal shortening was performed in 1 case, and chordal reconstruction using artificial chordae was employed in 2 cases. There was no operative death, and postoperative echocardiography showed no residual regurgitation in any of the cases. Conclusions: Mitral regurgitation associated with undifferentiated papillary muscle resulted from prolapse or tethering and impaired flexibility of leaflets. It was possible to successfully treat the patients by mitral valve plasty unless complex congenital cardiac malformation coexisted. Detailed examinations of attached papillary muscle by echocardiography and intraoperative inspection are necessary and surgical techniques should be selected appropriately in each case

Toward the Synthesis of Paspaline-Type Indole-Terpenes: Stereoselective Construction of Core Scaffold with Contiguous Asymmetric Quaternary Carbon Centers

The core scaffold of paspaline-type indole-terpenes was synthesized by using the House–Meinwald rearrangement as a key step. Rearrangement of the epoxide methyl group in the precursor with MABR (methylaluminum bis(4-bromo-2,6-di-tert-butylphenoxide)) as a Lewis acid proceeded smoothly to construct contiguous asymmetric quaternary carbon centers by a 1,2-chirality transfer

Detailed Anatomy of Bridging Veins Around the Foramen Magnum: a Multicenter Study Using Three-dimensional Angiography

Background and Purpose　There has been limited literature regarding the bridging veins (BVs) of the medulla oblongata around the foramen magnum (FM). The present study aims to analyze the normal angioarchitecture of the BVs around the FM using slab MIP images of three-dimensional (3D) angiography. Methods　We collected 3D angiography data of posterior fossa veins and analyzed the BVs around the FM using slab MIP images. We analyzed the course, outlet, and number of BVs around the FM. We also examined the detection rate and mean diameter of each BV. Results　Of 57 patients, 55 patients (96%) had any BV. The median number of BVs was two (range: 0–5). The BVs originate from the perimedullary veins and run anterolaterally to join the anterior condylar vein (ACV), inferior petrosal sinus, sigmoid sinus, or jugular bulb, inferolaterally to join the suboccipital cavernous sinus (SCS), laterally or posterolaterally to join the marginal sinus (MS), and posteriorly to join the MS or occipital sinus. We classified BVs into five subtypes according to the draining location: ACV, jugular foramen (JF), MS, SCS, and cerebellomedullary cistern (CMC). ACV, JF, MS, SCS, and CMC BVs were detected in 11 (19%), 18 (32%), 32 (56%), 20 (35%), and 16 (28%) patients, respectively. The mean diameter of the BVs other than CMC was 0.6 mm, and that of CMC BV was 0.8 mm. Conclusion　Using venous data from 3D angiography, we detected FM BVs in most cases, and the BVs were connected in various directions

Effects of changing the timing of warfarin administration in combination with fluconazole on prolongation of the PT-INR: a case report

Abstract Background Fluconazole (FLCZ) inhibits cytochrome P450 (CYP) 2C9, 2C19, and 3A4 and has a drug-drug interaction that potentiates the effects of warfarin and prolong the prothrombin time-international normalized ratio (PT-INR). Although a drug-drug interaction have been reported between FLCZ and warfarin, the effects of the timing of their administration on this interaction have not yet been investigated. Case presentation A female patient in her 30s with Marfan syndrome had undergone the Bentall procedure with a mechanical valve and total arch replacement for acute aortic dissection Stanford A type and rupture of the ascending aorta. Warfarin was administered to prevent thromboembolism. She was hospitalized 1 year ago for graft infection caused by Candida albicans, and treatment with FLCZ was initiated. She received FLCZ 200 mg once a day in the morning and warfarin 1.75 mg once a day in the evening, and the PT-INR remained stable at approximately 2.0 and within the therapeutic range. However, 42 days after changing the timing of administration of warfarin from evening to morning, the PT-INR was prolonged by approximately 3-fold to 6.25. The PT-INR then decreased to the previous level by changing the timing of administration of warfarin from morning to evening. Conclusions The timing of administration of FLCZ and warfarin may affect the magnitude of drug-drug interaction

Comparison between valve-sparing root replacement and Bentall procedure in patients with Marfan syndrome

Background: Bentall procedure is standard procedure for aortic root aneurysm or dissection in patients with Marfan syndrome. The purpose of this study was to evaluate whether valve-sparing root replacement (VSR) can be an alternative to Bentall procedure in patients with Marfan syndrome. Methods: Thirteen patients with Marfan syndrome underwent aortic root replacement between 1999 and 2017. Bentall procedure with a mechanical valve was performed in 9 patients and VSR was performed in 4. The mean durations of follow-up were 103.1 ± 61.6 months in Bentall and 35.0 ± 26.4 months in VSR. Results: There was no in-hospital death in both procedures. Reoperation for bleeding was performed in one patient after Bentall procedure. One patient died because of unknown cause in the Bentall group. No death occurred in the VSR group during a follow-up period. There was no difference in mortality between two groups. In the Bentall group, subarachnoid hemorrhage was developed in one patient and cerebral hemorrhage in one, while there was no hemorrhage or thromboembolism in the VSR group. Echocardiography showed improvement of aortic valve regurgitation grade (pre-operation 2.9 ± 1.4 vs postoperation 0.5 ± 0.4, P = 0.03) in all patients of the VSR group, and there was no reoperation for aortic valve after VSR. Conclusion: The significant inferiority of both early and late result in VSR could not be observed. VSR avoids the risk of complications associated with anticoagulation, which can be a preferable alternative to Bentall procedure in patients with Marfan syndrome