Sumio Miura

Arteriovenous access closure in hemodialysis patients with refractory heart failure: a single center experience.

Arteriovenous dialysis access may impose a burden on the cardiac system. The objective of this study is to examine the usefulness of access closure in hemodialysis patients with refractory heart failure and to identify possible factors associated with symptomatic improvements. The study population comprised 33 hemodialysis patients with symptomatic heart failure (New York Heart Association [NYHA] class ≥II), who underwent arteriovenous access closure (30 fistulas and three grafts) between 1991 and 2008. In all patients, heart failure was refractory to all possible medical and surgical treatments, and persisted after optimal dry weight control. First, short‐term changes in hemodynamics, clinical symptoms and echocardiographic morphology were examined. Second, clinical and echocardiographic parameters were compared between responders (N = 23), who demonstrated NYHA class improvement after access closure, and non‐responders (N = 10). After access closure, systolic blood pressure rose and the heart rate decreased significantly. Body weight and echocardiographic parameters did not change significantly. Twenty‐three patients (70%) demonstrated NYHA class improvement and were designated as responders. In responders, the duration from access creation to closure was significantly shorter and fewer had ischemic heart disease, compared with non‐responders. Access flow, cardiac output and ejection fraction were comparable between the two groups. Although the five‐year survival was 20.2% in all patients, responders showed better early survival than non‐responders. Arteriovenous access closure improved clinical symptoms in 70% of patients with refractory heart failure. This improvement was especially likely to be achieved in patients without ischemic heart disease and those who developed heart failure within a relatively short time after access creation.

Study Design of PROCEDURE Study. A Randomized Comparison of the Dose-Dependent Effects of Pitavastatin in Patients with Abdominal Aortic Aneurysm with Massive Aortic Atheroma: Prevention of Cholesterol Embolization during Endovascular and Open Aneurysm Repair with Pitavastatin (PROCEDURE) Study.

Outcomes of abdominal aortic aneurysm (AAA) repair have improved in the 2 decades since the emergence of endovascular aneurysm repair (EVAR). However, EVAR is considered a contraindication for shaggy aorta because of the high risk of shower embolization. Recently, statins have been implicated in preventing embolization in patients with shaggy aorta via its pleiotropic effects, including atheroma reduction and coronary artery stabilization. We selected pitavastatin, a statin with potent effects, discovered and developed by a Japanese company because it has shown excellent pleiotropic effects on atheromatous arteries in the Japanese population. A randomized comparison study of dose-dependent effects of pitavastatin in patients with AAA with massive atheromatous aortic thrombus (PROCEDURE study) has begun. PROCEDURE has an enrollment goal of up to 80 patients with AAA with massive aortic atheroma (excluding intrasac atheroma), randomly allocated into 2 groups receiving pitavastatin at a dose of 1 or 4 mg/day. The endpoints of the PROCEDURE study include change in atheroma volume, major adverse events related to shower embolization after aneurysm repair, and lipid-lowering effects. When complete, results of the PROCEDURE study should provide objective evidence to use statins preoperatively for AAA with massive aortic atheroma.

Repeated mitral valve replacement in a patient with extensive annular calcification

BackgroundMitral valve replacement in the presence of severe annular calcification is a technical challenge.Case reportA 47-year-old lady who had undergone mitral and aortic valve replacement for rheumatic disease 27 years before presented with dyspnea. At reoperation, extensive mitral annular calcification was hindering the disc motion of the Starr-Edwards mitral prosthesis. The old prosthesis was removed and a St Jude Medical mechanical valve was implanted after thorough annular debridement. Postoperatively the patient developed paravalvular leak and hemolytic anemia, subsequently undergoing reoperation three days later. The mitral valve was replaced with an Edwards MIRA valve, with a bulkier sewing cuff, after more aggressive annular debridement. Although initially there was no paravalvular leak, it recurred five days later. The patient also developed a small cerebral hemorrhage. As the paravalvular leak and hemolytic anemia gradually worsened, the patient underwent reoperation 14 days later. A Carpentier-Edwards bioprosthetic valve with equine pericardial patches, one to cover the debrided calcified annulus, another as a collar around the prosthesis, was used to eliminate paravalvular leak. At 7 years postoperatively the patient is doing well without any evidence of paravalvular leak or structural valve deterioration.ConclusionMitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.

Papillary Fibroelastoma of the Left Ventricle: Report of Two Cases

Papillary fibroelastoma is a relatively rare cardiac tumor. We report two cases of papillary fibroelastoma. The first case involved a 45-year-old woman who presented with rheumatic valves and three tumors developing from the papillary muscle and left ventricle. The second case involved a 68-year-old man who was asymptomatic and whose tumor was detected incidentally on echocardiogram. Both cases were treated surgically. An additional 71 cases of papillary fibroelastoma reported in the medical literature in Japan are reviewed.

Mid-term results of a closed biatrial procedure using bipolar radiofrequency ablation concomitantly performed with non-mitral cardiac operations

The long-term success rate of the Cox maze III procedure is excellent, although it has not been widely adopted because of the need for extensive incisions of the atria. In this study, we report our experience with a closed biatrial procedure using bipolar radiofrequency (RF) ablation for treating atrial fibrillation (AF) during non-mitral cardiac operations. Beginning in December 2004, a total of 19 patients underwent a closed biatrial procedure with bipolar RF energy. All the patients had a maze procedure plus a concomitant non-mitral operation. Except for several stabs to introduce the bipolar device, no incisions were made in either atrium. The first six patients were investigated with 64-slice multidetector computed tomography (MDCT), six months after the operation. Patients were followed-up monthly with a clinical examination and electrocardiography. There were no operative deaths. MDCT showed no evidence of coronary sinus stenosis. At one year of follow-up, 93% of the patients (14/15) were in sinus rhythm. The closed biatrial procedure using bipolar RF ablation is safe and effective in treating AF during open-heart surgery. This could be particularly beneficial for patients with AF who are undergoing a cardiac surgical procedure without opening the left atrium.

Off-pump coronary artery bypass grafting in a patient with Werner’s syndrome

Werner’s syndrome is a rare hereditary disorder that is characterized by premature aging. We report a case of off-pump coronary artery bypass grafting (OPCAB) in a 56-year-old man with Werner’s syndrome. We used an endoscopic vessel-harvesting system to harvest great saphenous vein grafts (SVGs) because this system helps minimize surgical wounds. This is important because poor wound healing is a prominent feature of Werner’s syndrome. Revascularization of the coronary arteries in this case was thought to improve his prognosis, although he had already outlived the average life-span of Werner’s syndrome. A detailed examination of the cardiovascular system should be performed in patients with this disorder.

Transcatheter aortic valve implantation for patients with lung cancer and aortic valve stenosis

Many patients who require lung resection have cardiovascular and cerebrovascular comorbidities. It has been recommended that surgical aortic valve replacement (SAVR) should precede lung resection in patients with severe aortic valve stenosis (AS). However, by first undergoing transcatheter aortic valve implantation (TAVI), the patient may undergo lung resection more safely. We present two patients with both severe AS and lung cancer who underwent TAVI and lung resection without any complications.

Simultaneous transcatheter aortic valve implantation and endovascular aneurysm repair in a patient with very severe aortic stenosis with abdominal aortic aneurysm

The safety of non-cardiac surgery is uncertain for asymptomatic patients with very severe aortic stenosis (AS). Herein, we describe a case involving an elderly and frail patient with asymptomatic, very severe AS. The patient was considered a high-risk candidate for aortic valve replacement (AVR); thus, transcatheter aortic valve implantation (TAVI) was planned. On perioperative examination, an abdominal aortic aneurysm (AAA) was observed, which required endovascular aneurysm repair (EVAR). To reduce the risks involved with sequential procedures, TAVI and EVAR were performed simultaneously. In patients with severe AS who are high-risk candidates for AVR, TAVI can be considered as an alternative therapy before non-cardiac surgery. In addition, the combined TAVI and EVAR procedure can reduce the risks associated with the perioperative period. <Learning objective: For patients with severe aortic stenosis who are high-risk candidates for aortic valve replacement (e.g. elderly patients with comorbidities), transcatheter aortic valve implantation (TAVI) can be considered as an alternative therapy before non-cardiac surgery. In addition, combining TAVI and endovascular aneurysm repair can reduce the perioperative risks compared with those for sequential procedures. However, additional research is needed.>.

Transcatheter aortic valve implantation in a patient with severe aortic valve stenosis, colon cancer, and obstructive ileus: A case report

An 82-year-old woman with symptomatic severe aortic stenosis (AS) developed an obstructive ileus caused by colon cancer. Colectomy was considered a high-risk surgery due to both the severe AS and obstructive ileus. Therefore, we planned placement of a colonic stent for the obstructive ileus. After stenting, we performed transcatheter aortic valve implantation (TAVI) instead of surgical aortic valve replacement (SAVR), because of the risk of bleeding during extracorporeal circulation and the perioperative risk of AVR (Society of Thoracic Surgery predicted risk of mortality: 7.4%). Successful colonic stenting and TAVI allowed a safer colectomy. The period from TAVI to colectomy was 12 days. TAVI could be useful for symptomatic severe AS in high-risk patients prior to non-cardiac surgery, especially for malignant tumors. <Learning objective: In patients with symptomatic severe aortic stenosis, aortic valve replacement is recommended prior to non-cardiac surgery. However, in patients with a malignancy, the complications due to the tumor and the risk of extracorporeal circulation remain a challenge in surgical aortic valve replacement. In such cases, transcatheter aortic valve implantation may be a useful option to reduce the incidence of complications and the time to surgery for the malignancy.>.

Efficacy of Pericardial Drainage in Annular Rupture and Periaortic Hematoma After Transcatheter Aortic Valve Replacement

Received January 30, 2018; revised manuscript received May 1, 2018; accepted May 17, 2018; released online June 22, 2018 Time for primary review: 21 days Division of Cardiology (T.T., K.Y., T.O., K.S., K.T.), Division of Cardiovascular Surgery (A.O., S.M.), Division of Anesthesia (M.Y.), Mitsui Memorial Hospital, Tokyo, Japan Mailing address: Kazuyuki Yahagi, MD, Division of Cardiology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho, Chiyoda-ku, Tokyo 101-8643, Japan. E-mail: yyahakazu@gmail.com ISSN-1346-9843 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp Efficacy of Pericardial Drainage in Annular Rupture and Periaortic Hematoma After Transcatheter Aortic Valve Replacement