Shizuyuki Dohi

Effect of preoperative hemoglobin A1c levels on long-term outcomes for diabetic patients after off-pump coronary artery bypass grafting

BACKGROUND Diabetes mellitus is an independent risk factor for cardiovascular events after coronary artery bypass grafting (CABG), and hemoglobin A1c (HbA1c) is the most convenient marker for monitoring glycemic control among diabetic patients. However, few studies have reported the impact of baseline HbA1c levels on outcomes for diabetic patients after CABG. This study therefore aimed to investigate whether preoperative HbA1c levels in diabetic patients are predictive of long-term outcomes after off-pump CABG (OPCAB). METHODS AND RESULTS Of 893 patients undergoing primary isolated OPCAB at Juntendo University Hospital from July 2002 to December 2007, subjects comprised 306 diabetic patients <80 years old. We divided these patients into 3 groups according to the preoperative HbA1c levels. No significant differences in baseline characteristics, angiographic findings, or operative parameters were apparent among the 3 groups. No operative or in-hospital mortality occurred. All-cause mortality and cardiac mortality rates were 6.2% (19 cases) and 1.3% (4 cases), respectively. Kaplan-Meiers survival showed no significant differences in all-cause or cardiac mortality (log-rank test, p=0.26, p=0.17, respectively). Multivariate analysis by Coxs proportional hazards model also demonstrated that no covariates predicted mortality except for age. CONCLUSIONS Preoperative HbA1c levels might not predict long-term outcomes for diabetic patients undergoing OPCAB. Careful evaluation for diabetes should be needed in preoperative management of CABG.

Metal allergy to stainless steel wire after coronary artery bypass grafting.

Abstract To our knowledge, this is the first reported case of a manganese metal allergy to stainless steel wire. A 51-year-old man suffered from a refractory pruritic erythematous wheal after the insertion of a stainless steel wire. The patch test showed strong reactions to manganese, one of the constituents of stainless steel wire. After the removal of all stainless steel wires, the symptoms were much improved, except for mild pruritus on his face.

Comparing outcomes after off-pump coronary artery bypass versus drug-eluting stent in diabetic patients

BACKGROUND Off-pump coronary artery bypass surgery and sirolimus-eluting stent placement have been widely used for the treatment of coronary artery disease. The goal of this study was to compare long-term outcomes after off-pump coronary artery bypass surgery or sirolimus-eluting stent placement in diabetic patients with multivessel disease. METHODS This observational study enrolled 350 off-pump coronary artery bypass patients and 143 sirolimus-eluting stent patients receiving care at our institution between 2000 and 2007. All patients had diabetes and multivessel disease including proximal left anterior descending or left main coronary artery. The choice of revascularization (percutaneous coronary intervention versus coronary artery bypass surgery) was left to the physicians discretion rather than randomization. Cox proportional-hazard analyses, adjusting baseline risk factors and propensity score, which predicted the probability of receiving off-pump coronary artery bypass, were conducted to evaluate outcomes, including all-cause mortality, cardiac death, target vessel revascularization, and major adverse cardiac and cerebrovascular events. RESULTS During the follow-up (2.6±1.6 years) period, there was no difference between off-pump coronary artery bypass and sirolimus-eluting stent placement in all-cause mortality or cardiac death. However, the incidences of acute coronary syndrome, target vessel revascularization, and major adverse cardiac and cerebrovascular events were markedly lower in the patients undergoing off-pump coronary artery bypass than in those receiving sirolimus-eluting stent placement. CONCLUSION Off-pump coronary artery bypass is superior to sirolimus-eluting stent placement in terms of acute coronary syndrome, target vessel revascularization, and major adverse cardiac and cerebrovascular events in diabetic patients with multivessel coronary artery disease.

Predictors of Early and Mid-Term Results in Contemporary Aortic Valve Replacement for Aortic Stenosis

Abstract  Background: The purpose of this study was to evaluate clinical risk factors and assess the impact of the Society of Thoracic Surgeons (STS) scores on outcomes after contemporary aortic valve replacement (AVR) for aortic stenosis (AS). Methods: We retrospectively analyzed the data from 209 consecutive patients with AS (mean 69 ± 9 years) who underwent AVR. The outcomes measured included operative mortality, postoperative complications, postoperative prolonged length of stay (PLOS), discharge to nonhome location, and mid‐term mortality. Results: Operative mortality was 3.8%, and five‐year survival was 88.6 ± 2.8%. Multivariable analysis revealed preoperative New York Heart Association (NYHA) class as a significant predictor of both operative mortality (p = 0.03; odds ratio [OR]: 8.5) and mid‐term mortality (p = 0.02; OR: 10.5). NYHA class also emerged as an independent predictor for postoperative complications (p = 0.002; OR: 5.8) and PLOS (p = 0.01; OR: 2.5). Other preoperative independent predictors included dialysis for PLOS (p = 0.04; OR: 2.9), age (p = 0.03; OR: 1.1), and left ventricular ejection fraction (EF; p = 0.03; OR: 0.9) for nonhome discharge, and EF for mid‐term mortality (p = 0.01; OR: 0.9). The mean STS‐PROM (predicted risk of mortality) was 4.6% ± 6.1%, and thus, the observed‐to‐expected (O/E) ratio of operative mortality in our series was 0.82. Conclusions: Advanced NYHA class, older age, dialysis, and lower EF are significant independent preoperative risk factors for early and mid‐term results of AVR for AS. Consideration of these predictors should be used to identify high‐risk patients requiring AVR for AS.

Aortic and mitral valve replacement in a patient with acute febrile neutrophilic dermatosis (Sweet's syndrome): report of a case.

Abstract A 29-year-old woman was admitted to our hospital with severe orthopnea, fever, and acute dermatosis. She had a 5-year history of episodic acute neutrophilic dermatosis and peripheral leukocytosis following a high fever, which were symptoms consistent with a diagnosis of Sweets syndrome. Echocardiography revealed remarkable dysfunction of the left ventricle due to severe aortic regurgitation, which had not been present at a previous admission when mild mitral regurgitation was detected. The aortic and mitral valves were replaced with prosthetic valves on an emergency basis. The leaflets of the aortic valve were very thin and appeared fragile. The anterior leaflet of the mitral valve showed severe prolapse due to the torn chordae and hypoplasia of the posterior strut chordae. Her postoperative course was uneventful. Microscopic examination revealed fibrosal degeneration and the infiltration of lymphocytes and macrophages into both heart valves. This may be the first case report of valvulitis and Sweets syndrome occurring simultaneously.

Off-pump coronary artery bypass grafting in a patient with liver cirrhosis

We report a case of unstable angina pectoris and alcohol-related Child-Pugh class B cirrhosis. The patient was a 60-year-old man who was admitted to hospital with chest pain. He had previously been diagnosed to have Child B cirrhosis due to alcoholic liver dysfunction at 58 years of age. He also had experienced ruptured esophageal varices, moderate ascites, and hyperammonemia. We performed percutaneous catheter intervention; however, he developed re-stenosis in the right coronary artery, and progression in the disease in other coronary arteries. We then performed coronary artery bypass grafting on the beating heart without cardiopulmonary bypass. He was discharged on the 13th postoperative day without any complications. This case demonstrated that off-pump coronary artery bypass grafting was safe for such a patient.

Comparison of modern risk scores in predicting operative mortality for patients undergoing aortic valve replacement for aortic stenosis

BACKGROUND The aim of our study was to examine and compare the predictive value of operative mortality of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, the Society of Thoracic surgeons (STS) score, the Ambler score, and the Japan score in patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). METHODS A total of 406 patients undergoing AVR with or without coronary artery bypass grafting (CABG, n=139) at our institution from August 2002 to December 2013 were enrolled in this cohort study. Accuracy of calibration and discrimination performance of four risk scores was assessed in the overall patient population and quartiles of each risk score. RESULTS Operative mortality was 3.4% (n=14). The mean EuroSCORE II, STS score, Ambler score, and the Japan score were 3.1%, 4.9%, 5.7%, and 3.2%, respectively, giving observed-to-expected (O/E) ratio of 1.09, 0.69, 0.59, and 1.06. The C-statistics for operative mortality were 0.704 (EuroSCORE II), 0.781 (STS score), 0.709 (Ambler score), and 0.771 (Japan score). In the last quartile, the EuroSCORE II demonstrated excellent calibration (O/E ratio=0.97) and discrimination (C-statistic=0.904), and the STS score (O/E ratio=0.86, C-statistic=0.779) and the Japan score (O/E ratio=1.14, C-statistic=0.80) showed reasonable correlation. However, the risk calibration by the Ambler score in the last quartile was unacceptable (O/E ratio=0.60). CONCLUSIONS The EuroSCORE II and the Japan score showed superior ability of calibration, but the STS score and the Ambler score overestimated the risk. However, the discrimination power was similar among the four risk scores. In the last quartile of risk, the EuroSCORE II gave an excellent predictive performance.

Preoperative hepatic dysfunction could predict postoperative mortality and morbidity in patients undergoing cardiac surgery: Utilization of the MELD scoring system.

BACKGROUND According to recent advances in operative techniques, an increasing number of patients with liver dysfunction have been subjected to cardiac surgery. Model of End-Stage Liver Disease (MELD and MELD-XI) scores allow risk stratification of patients undergoing cardiac and non-cardiac surgeries. METHODS We retrospectively analyzed 1856 consecutive patients (69.3% male, mean 66.8 ± 12.2 years) undergoing cardiac surgery between 2008 and 2013 at our institution. RESULTS The mean values of MELD/MELD-XI scores obtained from the total cohort were 9.7 ± 4.6/11.9 ± 4.8. Patients with high MELD/MELD-XI scores (>12) were older, more anemic, and had lower left ventricular ejection fraction than those with low scores (all p<0.0001). High scores were associated with longer hospitalization (36.8 ± 33.0 vs. 23.6 ± 21.5 days for MELD, 36.7 ± 34.0 vs. 23.5 ± 21.0 days for MELD-XI, both p<0.0001) and higher in-hospital all-cause mortality (6.6% vs. 1.0% for MELD, 7.7% vs. 0.7% for MELD-XI). Atrial fibrillation occurred more frequently in the high MELD group, but this difference was not found for MELD-XI. MELD/MELD-XI could predict mortality with a sensitivity of 64.3%/60.0% and specificity of 79.1%/85.3%. Comparison of AUC values among MELD scores, individual MELD components, and Child-Turcotte-Pugh (CTP) classification showed that the predictive strength of MELD scores for mortality was stronger than individual parameters or CTP classification (AUC: 0.7702 for MELD, 0.7655 for MELD-XI, 0.5799 for CTP classification with pairwise p<0.0001 and p=0.0002 vs. MELD and MELD-XI, respectively). CONCLUSIONS Assessment of liver dysfunction using the MELD scores can be useful for predicting postoperative morbidity and mortality, which may allow additional risk stratification in patients undergoing cardiac surgery.

Skeletonized Gastroepiploic Artery for Off-Pump Coronary Artery Bypass Grafting

BACKGROUND Skeletonized arterial grafting may reduce the risk of graft spasm and may improve graft patency. Previously we reported a pilot study of skeletonized gastroepiploic artery (GEA) grafting with favorable results. Skeletonized GEA harvesting with an ultrasonic scalpel has now become our routine procedure. In this report, we compare the early clinical outcomes of skeletonized versus pedicled GEA grafting to assess the safety and benefit of use of skeletonized GEA in coronary artery bypass grafting. METHODS Between July 2002 and October 2003, the GEA was used as a conduit for isolated off-pump coronary artery bypass grafting in 105 patients. Of these, 21 patients (group P) received pedicled GEA and 59 patients (group S) received skeletonized GEA grafts (excluding 25 patients whose results were reported in the pilot study). The perioperative and early follow-up data were prospectively collected and compared. RESULTS No graft injury was found in either group. The preoperative characteristics were similar in the two groups except that group S had a smaller body surface area (1.64 +/- 0.16 m 2 in group S versus 1.73 +/- 0.16 m 2 in group P, P <.05) and a significant number of patients with diabetes (36/59, 61.0% versus 7/21, 33.3%, P <.05). The number of distal anastomoses was 4.3 < 1.0 versus 3.9 +/- 0.9 ( P = not significant [NS]). An in situ GEA composite graft was constructed in 8 (13.6%) of the patients in group S and none of the patients in group P ( P = NS). There was one hospital death due to infection in group S. Otherwise, there were no cases of low output syndrome or postoperative myocardial infarction in either group. During early postoperative follow-up, no angina recurrence or myocardial infarction was found. CONCLUSION The GEA can be skeletonized safely with an ultrasonic scalpel. Skeletonization enables a wider variety of choices in the use of GEA grafting.

Low Serum Levels of EPA are Associated with the Size and Growth Rate of Abdominal Aortic Aneurysm

Aim: Omega-3 polyunsaturated fatty acids (PUFAs) such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been reported to reduce the risk of cardiovascular disease. However, whether omega-3 PUFAs are involved in the pathogenesis of abdominal aortic aneurysms (AAA) remains unclear. Methods: We analyzed 67 consecutive patients admitted for the elective surgical repair of AAA. We investigated the association of serum EPA and DHA levels as well as the EPA/AA ratio with the size of AAA assessed using three-dimensional reconstructed computed tomography images. Results: Mean patient age was 70 ± 9 years and 60 patients were male. Serum EPA and DHA levels were 75.2 ± 35.7 µg/mL and 146.1 ± 48.5 µg/mL, respectively. EPA/AA ratio was 0.44 ± 0.22, which was lower than those in healthy Japanese subject and equivalent to those in Japanese patients with coronary artery disease as previously reported. Mean of the maximum AAA diameter was 56.4 ± 8.9 mm, and serum EPA levels and EPA/AA ratio negatively correlated with it (r = −0.32 and r = −0.32, respectively). Multiple liner regression analysis showed that EPA levels were significant independent factor contributing to the maximum AAA diameter. Furthermore, low serum EPA levels and low EPA/AA ratio were significantly associated with the growth rate of AAA diameter (r = −0.43 and r = −0.33, respectively). Conclusion: EPA levels in patients with AAA were relatively low. Low serum EPA levels and EPA/AA ratio were associated with the size and growth rate of AAA.