Abnormal Tei index predicts poor left ventricular mass regression and survival after AVR in aortic stenosis patients

SummaryBackgroundA Tei index is known to reflect overall cardiac performance including systolic and diastolic function in a variety of heart disease. We investigated the relationship between preoperative Tei index and postoperative left ventricular (LV) mass regression and survival after aortic valve replacement (AVR) for aortic valve stenosis (AS).MethodsOne hundred fifty-four patients with AS were classified into a group with abnormal (Abn) LV function (n=47, 0.45≤Tei index) and a group with normal (Nor) LV function (n=107, Tei index<0.45). The pre- and postoperative echocardiographic variables including LV dimension, LV wall thickness, and LV mass regression as well as 6-year survival were compared between the two groups.ResultsThere was a significant difference in both absolute and relative LV mass index (LVMI) regression (P=0.004 and 0.0007). Multiple linear regression analysis revealed that the preoperative LVMI, Tei index, and follow-up period were independent predictors of LVMI regression after AVR. Thirteen patients died (valve-related death in 5). Although the overall survival rate in the Nor-LV group (92.8%) was significantly better than that in the Abn-LV group (71.6%), there was no significant difference in survival free from valve-related death.ConclusionsPreoperative Tei index can be one of the significant predictors of LVMI regression and overall survival after AVR

Alternative redo sternotomy in a patient with tracheostoma and patent grafts.

We describe a redo mitral valve replacement operation in a 71-year-old man with a tracheostoma and patent bypass grafts to the coronary arteries. Preoperative investigations revealed that the patent right internal thoracic artery graft ran directly under the sternum just anterior to the ascending aorta, and a saphenous vein graft was adhering to a surgical wire. To prevent injury to the patent grafts and cardiac structures, and to avoid communication with the tracheostoma, the redo procedure was performed via an anterior minithoracotomy combined with a low T-shaped partial sternotomy. The reoperation was successfully completed without any complications

Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis

AbstractBackgroundCurrent guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS).ObjectivesThe study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS.MethodsWe used data from a large multicenter registry enrolling 3,815 consecutive patients with severe AS (peak aortic jet velocity >4.0 m/s, or mean aortic pressure gradient >40 mm Hg, or aortic valve area <1.0 cm2) between January 2003 and December 2011. Among 1,808 asymptomatic patients, the initial AVR and conservative strategies were chosen in 291 patients, and 1,517 patients, respectively. Median follow-up was 1,361 days with 90% follow-up rate at 2 years. The propensity score–matched cohort of 582 patients (n = 291 in each group) was developed as the main analysis set for the current report.ResultsBaseline characteristics of the propensity score–matched cohort were largely comparable, except for the slightly younger age and the greater AS severity in the initial AVR group. In the conservative group, AVR was performed in 41% of patients during follow-up. The cumulative 5-year incidences of all-cause death and heart failure hospitalization were significantly lower in the initial AVR group than in the conservative group (15.4% vs. 26.4%, p = 0.009; 3.8% vs. 19.9%, p < 0.001, respectively).ConclusionsThe long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in this real-world analysis and might be substantially improved by an initial AVR strategy. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140

Induction and Enhancement of Cardiac Cell Differentiation from Mouse and Human Induced Pluripotent Stem Cells with Cyclosporin-A

Induced pluripotent stem cells (iPSCs) are novel stem cells derived from adult mouse and human tissues by reprogramming. Elucidation of mechanisms and exploration of efficient methods for their differentiation to functional cardiomyocytes are essential for developing cardiac cell models and future regenerative therapies. We previously established a novel mouse embryonic stem cell (ESC) and iPSC differentiation system in which cardiovascular cells can be systematically induced from Flk1+ common progenitor cells, and identified highly cardiogenic progenitors as Flk1+/CXCR4+/VE-cadherin− (FCV) cells. We have also reported that cyclosporin-A (CSA) drastically increases FCV progenitor and cardiomyocyte induction from mouse ESCs. Here, we combined these technologies and extended them to mouse and human iPSCs. Co-culture of purified mouse iPSC-derived Flk1+ cells with OP9 stroma cells induced cardiomyocyte differentiation whilst addition of CSA to Flk1+ cells dramatically increased both cardiomyocyte and FCV progenitor cell differentiation. Spontaneously beating colonies were obtained from human iPSCs by co-culture with END-2 visceral endoderm-like cells. Appearance of beating colonies from human iPSCs was increased approximately 4.3 times by addition of CSA at mesoderm stage. CSA-expanded human iPSC-derived cardiomyocytes showed various cardiac marker expressions, synchronized calcium transients, cardiomyocyte-like action potentials, pharmacological reactions, and ultra-structural features as cardiomyocytes. These results provide a technological basis to obtain functional cardiomyocytes from iPSCs

Perioperative control of blood glucose level in cardiac surgery.

It is well recognized that poor perioperative blood glucose (BG) control can increase the risk of infection, cardiovascular accidents, and even death in patients undergoing cardiac surgery. Since it has been reported that tight BG control (80-110 mg/dL) yields better outcomes in critically ill patients, it became a standard of care to control BG using intravenous insulin infusion in ICU. However, it has been debated in terms of the optimal target range whether a strict control with intensive insulin therapy is better than liberal control. Because strict BG control can often cause hypoglycemia, which in turn increases the hospital mortality. In fact, a meta-analysis of randomized clinical trials concluded that tight BG control was not associated with significantly reduced hospital mortality but was associated with an increased risk of hypoglycemia. According to the current published guidelines, it seems to be optimal to control BG level of 140-180 mg/dL in ICU. In terms of more strict BG control (110-140 mg/dL), it may be appropriate in selected patients as long as this can be achieved without significant hypoglycemia

Hospital volume and outcomes of cardiothoracic surgery in Japan: 2005-2009 national survey.

To elucidate the relationship between hospital volume and cardiothoracic surgical outcomes in Japan using the annual survey data, obtained between 2005 and 2009, collected by the Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery

Bilateral atrial appendage aneurysms associated with atrial fibrillation.

Aneurysm of the left atrial appendage is an extremely rare anomaly. We describe the case of a 68-year-old man who presented with palpitation and was found to have a very large aneurysm located near the left atrial appendage on routine echocardiography. During surgery, an additional small aneurysm of the right atrial appendage was found. Both atrial aneurysms were resected in addition to mitral annuloplasty and a maze procedure