Abstract Objective To investigate the impact of preoperative identification of the Adamkiewicz artery (AKA) on prevention of spinal cord injury (SCI) through the multicenter Japanese Study of Spinal ...Cord Protection in Descending and Thoracoabdominal Aortic Repair (JASPAR) registry. Methods Between January 2000 and October 2011, 2435 descending/thoracoabdominal aortic repairs were performed, including 1998 elective repairs and 437 urgent repairs, in 14 major centers in Japan. The mean patient age was 67 ± 13 years, and 74.2% were males. There were 1471 open repairs (ORs), including 748 descending and 137 thoracoabdominal extent Ex I, 136 Ex II, 194 Ex III, 115 Ex IV, and 138 Ex V, and 964 endovascular repairs (EVRs). Of the 2435 patients, 1252 (51%) underwent preoperative magnetic resonance or computed tomography angiography to identify the AKA. Results The AKA was identified in 1096 of the 1252 patients who underwent preoperative imaging (87.6%). Hospital mortality was 9.2% (n = 136) in those who underwent OR and 6.4% (n = 62) in those who underwent EVR. The incidence of SCI was 7.3% in the OR group (descending, 4.2%; Ex I, 9.4%; Ex II, 14.0%; Ex III, 14.4%; Ex IV, 4.2 %; Ex V, 7.2%) and 2.9% in the EVR group. The risk factors for SCI in ORs were advanced age, extended repair, emergency, and occluded bilateral hypogastric arteries. In ORs of the aortic segment involving the AKA, having no AKA reconstruction was a significant risk factor for SCI (odds ratio, 2.79, 95% confidence interval, 1.14-6.79; P = .024). Conclusions In descending/thoracoabdominal aortic repairs, preoperative AKA identification with its adequate reconstruction or preservation, especially, in ORs of aortic pathologies involving the AKA, would be a useful adjunct for more secure spinal cord protection.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective For aortic arch aneurysms, conventional total arch replacement has been the standard surgical option. In selected high-risk patients, we have attempted less invasive hybrid procedure ...involving supra-aortic bypass and endovascular stent-graft placement. We review the early and midterm outcomes to clarify the impact of the hybrid procedure. Methods Between October 2007 and December 2010, 27 patients were treated with the hybrid procedure. During the same period, 191 patients underwent elective conventional total arch replacement. On retrospective analysis, the hybrid procedure was feasible in 103 patients (hybrid feasible) and not feasible in 88 patients (hybrid impossible). Patients undergoing the hybrid procedure attained significantly higher additive (11.6 ± 2.2 vs 9.5 ± 2.4, 10.3 ± 2.8, P < .001, P = .044) and logistic (31.1 ± 14.1 vs 18.8 ± 12.6, 23.7 ± 16.0, P < .001, P = .047) European System for Cardiac Operative Risk Evaluation scores than hybrid-feasible and hybrid-impossible groups. Results Although the patients in the hybrid group had significantly higher risk, the early outcomes including mortality and morbidity were similar among the 3 groups, as were the 2-year survivals during the follow-up period: 85.9% for the hybrid group, 89.6% for the hybrid-feasible group, and 86.7% for the hybrid-impossible group ( P = .510, .850, log-rank test). In the hybrid group, 2 patients required reintervention for type I endoleak. Conclusions The early and midterm outcomes of the hybrid procedure for aortic arch aneurysms were satisfactory. This procedure has the potential to be an alternative for conventional total arch replacement for high-risk patients.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective With the recent advance of endovascular aortic repair, conventional open repair for aortic arch lesions should be reassessed. We reviewed our contemporary open arch repair with selective ...antegrade cerebral perfusion by way of the axillary artery with deep or moderate hypothermia. Methods From 2001 to 2011, 1007 patients (median age, 72 years) underwent open arch repair with selective cerebral perfusion through the right axillary artery and hypothermic circulatory arrest: deep (<25°C) in 48% and moderate (25°-28°C) in 52%. Of the 1007 patients, 73% underwent total arch replacement and 26% emergent surgery for aneurysm rupture or acute aortic dissection. Results The early mortality was 4.7% for all patients. Permanent and temporary neurologic dysfunction occurred in 3.5% and 6.7%, respectively. No spinal cord injury occurred, even with moderate hypothermia. The independent predictors of in-hospital mortality included chronic obstructive pulmonary disease, liver dysfunction, chronic kidney disease, and concomitant coronary artery bypass. The independent predictors of permanent neurologic dysfunction included cerebrovascular disease, emergency surgery, and concomitant coronary artery bypass. The cumulative survival rate was 80.4% and 71.2% at 5 and 8 years, respectively. Freedom from reoperation related to the initial arch repair was 98.0% and 96.9% at 5 and 8 years, respectively. Conclusions Conventional open arch repair yielded satisfactory outcomes and should remain the standard therapy, with good long-term durability in all but high-risk patients.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background This article discusses the multidisciplinary approach to prevent spinal cord ischemia (SCI) with reference to the incidence of SCI after thoracic endovascular aneurysm repair (TEVAR) ...associated with closure of the intercostal-lumbar artery that supplies the Adamkiewicz artery (ICA-AKA). Methods We reviewed 60 patients 49 men, 57 to 89 years old who underwent TEVAR (TAG W. L. Gore & Associates, Flagstaff, AZ 42; the Matsui-Kitamura (Kanazawa, Japan) 10; Talent Medtronic Inc, Santa Rosa, CA 5; TAG and Talent 3) for part of or the entire distal descending aorta between T7 and L2. These patients had frequently undergone aortic surgeries: ascending aorta (4), aortic arch (25), descending aorta (4), thoracoabdominal aorta (3), and abdominal aorta (19). The multidisciplinary approach consists of identification of the ICA-AKA by magnetic resonance angiography or computed tomographic angiography to avoid unnecessary coverage of the ICA-AKA, in combination with monitoring of motor evoked potentials, augmentation of mean arterial pressure (> 80 mm Hg), and cerebrospinal fluid drainage. Results Spinal cord ischemia occurred in 4 patients and patent ICA-AKAs were covered in 3 of them. The overall incidence of SCI was 6.7% and 9.4% in the group of 32 patients whose patent ICA-AKAs were covered by TEVAR. After treatment for SCI, 3 patients regained full ambulatory ability. Significant risk factors were identified as the artificial graft at the proximal landing zone, the number of covered zones (>8), the length of aortic coverage (>250 or >300 mm), and the length of the uncovered distal aorta (<60 mm). Conclusions A multidisciplinary approach is essential to prevent SCI after TEVAR for the distal descending aorta. This approach includes the preservation of patent ICA-AKAs after their identification, early diagnosis of SCI during TEVAR by monitoring motor evoked potentials, and prophylaxis and treatment of SCI by increasing mean arterial pressure to at least 80 mm Hg and performing cerebrospinal fluid drainage.
Abstract Background Research on the correlation of serum bilirubin level with cardiac function as well as outcomes in heart failure patients with cardiac resynchronization therapy (CRT) has not yet ...been reported. The aim of this study was to analyze the relationship between change in serum bilirubin level and left ventricular reverse remodeling, and also to clarify the impact of bilirubin change on clinical outcomes in CRT patients. Methods We evaluated 105 consecutive patients who underwent CRT. Patients who had no serum total-bilirubin data at both baseline and 3–9 months’ follow-up or had died less than 3 months after CRT implantation were excluded. Accordingly, a total of 69 patients were included in the present analysis. The patients were divided into two groups: decreased bilirubin group (serum total-bilirubin level at follow-up ≤ that at baseline; n = 48) and increased bilirubin group (serum total-bilirubin level at follow-up > that at baseline; n = 21). Results Mean follow-up period was 39.3 months. In the decreased bilirubin group, mean left ventricular end-systolic diameter decreased from 54.5 mm to 50.2 mm ( p = 0.001) and mean left ventricular ejection fraction increased significantly from 29.8% to 37.0% ( p = 0.001). In the increased bilirubin group, there was no significant change in echocardiographic parameters from baseline to follow-up. In Kaplan–Meyer analysis, cardiac mortality combined with heart failure hospitalization in the increased bilirubin group was significantly higher than that in the decreased bilirubin group (log-rank p = 0.018). Multivariate Cox regression analysis revealed that increased bilirubin was an independent predictor of cardiac mortality combined with heart failure hospitalization (OR = 2.66, p = 0.023). Conclusions The change in serum bilirubin is useful for assessment of left ventricular reverse remodeling and prediction of outcomes in heart failure patients with CRT.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background This study determined the midterm outcome of valve-sparing aortic root replacement for patients with inherited connective tissue disorders. Methods From 1993 to 2008, 94 patients underwent ...valve-sparing aortic root replacement. Sixty patients (64%), average age 33 years (range, 15 to 61 years), had inherited connective tissue disorders: Marfan syndrome, 54 (92%); Loeys-Dietz syndrome, 5 (8%); and smooth muscle α-actin ( ACTA2 ) mutation in 1. Median preoperative sinus diameter was 52 mm (range, 42 to 76 mm), and moderate/severe aortic regurgitation was present in 14 (23%). Seven (12%, 1993 to 1999) underwent remodeling procedures, and 53 had reimplantation procedures. Cusp repair was performed in 4. Median follow-up was 55 months (range, 1 to 149 months). There were 15 patients in the early term (1993 to 2000) and 45 in the late term (2001 to 2008). Results Four late deaths occurred (cardiac, 3; aortic, 1), with 10-year survival of 86%. Rates of freedom from aortic valve replacement at 5 and 10 years were 85% and 58% in remodeling and 96% and 58% in reimplantation. Risk factors for reoperations were postprocedure intraoperative aortic insufficiency greater than mild ( p = 0.046), remodeling procedure ( p = 0.016), and early term ( p = 0.0002). One patient (2%) with none/trivial postprocedure aortic insufficiency required aortic valve replacement. Freedom from reoperation in patients with none/trivial postprocedure aortic insufficiency at 5 and 10 years was 100% and 67%. Conclusions Meticulous control of aortic insufficiency during operation would bring favorable midterm durability in valve-sparing aortic root replacement using a reimplantation technique, even in patients with inherited connective tissue disorders.
Background Loeys-Dietz syndrome (LDS) is a recently recognized connective tissue disorder (CTD) caused by mutations in transforming growth factor-beta receptor (TGFBR)1 and TGFBR 2. Surgical outcomes ...of aortic repair in patients with LDS are poorly known. Methods We enrolled 16 patients with TGFBR mutations identified by gene analysis in this study. Between 1993 and 2011, they underwent 41 aortic surgical procedures. Ten patients (group D: dissection group) underwent aortic repair for acute or chronic aortic dissection as a first surgical intervention, and 6 patients (group N: nondissection group) underwent surgical treatment for aortic root dilatation. The mean follow-up period was 103.7 ± 92.3 months (range, 2– 276 months). Results There were no in-hospital deaths. In group N, valve-sparing root replacement (VSRR) was performed in all patients. The residual aorta in 9 patients (90%) from group D required further repairs, 3 times on average. Moreover, in 4 patients (40%), the aorta was entirely replaced in serial procedures. In group N, aortic dissection occurred in only 1 patient (17%). The aortic event-free rates at 5 years were 40% in group D and 80% in group N, respectively ( p = 0.819). One late death due to arrhythmia occurred 1 month after VSRR. The cumulative survival rates at 5 years were 100% in group D and 83% in group N, respectively ( p = 0.197). Conclusions Surgical outcomes for patients with LDS were satisfactory. Once aortic dissection occurred, the aorta expanded rapidly, requiring further operations. Therefore, early surgical intervention may improve prognosis by preventing a fatal aortic event.
Abstract Background The effect of cardiac pacing on sleep-disordered breathing is controversial. We investigated the long-term effect of cardiac pacing on sleep disordered breathing in patients with ...conventional indications for permanent pacemakers Methods Subjects comprised 40 patients (29 men; mean age 69±9 years, mean left ventricle ejection fraction 69±8%, and body mass index 23.6±3.5 kg/m2 ) who were diagnosed with indications for permanent pacemakers (sick sinus syndrome in 23 patients, atrioventricular block in 15, and brady atrial fibrillation in 2). All patients received polysomnographic evaluations before implantation of permanent pacemakers. After implantation of permanent pacemakers, all patients received polysomnographic evaluations during use of the pacemaker settings (AAI/DDD/VVI at 70 beats per minute). Results The mean follow-up period was 35±13 months. Before implantation, the distribution of sleep-disordered breathing was as follows: 93% had apnea hypopnea index >5, 58% had apnea hypopnea index >15, and 20% had apnea hypopnea index >30. The mean apnea hypopnea index for all patients was 20±15, for those with obstructive type apnea was 4.9±5.3, and for those with central type apnea was 3.0±4.5. The mean Epworth Sleepiness Score was 5.9±4.0. No patient received continuous positive airway pressure therapy or any other therapy for sleep-disordered breathing during the follow up period. The mean apnea hypopnea index at 1 week after implantation of permanent pacemakers was 21±14 ( P =0.8) and the mean apnea hypopnea index at end of follow-up was 11±7 ( P <0.0001). Conclusion Long term cardiac pacing significantly reduces the number of episodes of sleep apnea in patients with conventional permanent pacemaker indications.
Full text
Available for:
FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, VSZLJ, ZAGLJ, ZRSKP
Abstract Patients with corrected transposition of great arteries (c-TGA) are generally known to develop atrioventricular block, systemic right ventricular dysfunction, and tricuspid regurgitation ...over time, which are associated with tachyarrhythmia and progressive heart failure. A 76-year-old man had been diagnosed with c-TGA. He developed a cardiopulmonary arrest while playing tennis, and an automated external defibrillator detected ventricular fibrillation (VF). Immediate cardiopulmonary resuscitation and intensive treatment were performed. He fully recovered without neurological sequelae. QRS duration was 172 ms. Echocardiography showed marked dysfunction and dyssynchrony of the systemic right ventricle (systemic right ventricular end-diastolic diameter/end-systolic diameter = 73/60 mm, systemic right ventricular ejection fraction = 34%). For secondary prevention and treatment of progressive heart failure, cardiac resynchronization therapy with defibrillator (CRT-D) implantation was recommended. Venography via the left cubital superficial vein revealed a persistent left superior vena cava (PLSVC) and giant coronary sinus that did not connect with the right superior vena cava (SVC). Because of the acute angle between the PLSVC and great cardiac vein, we selected a right-sided approach via the right SVC. We were finally able to deliver a coronary sinus lead to the lateral vein. CRT-D implantation can be achieved even in patients with c-TGA and PLSVC. < Learning objective: CRT-D implantation can be achieved even in a patient with c-TGA and PLSVC.>
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
A lightpath design and management tool with parallel processing capabilities and a flexible upgradability, allowing new functions to be added to the system without any system program changes, has ...been designed and implemented for IP-over-CWDM networks with ROADMs. The tool can process applications composed of some sub applications in parallel in multi machines for high-speed performance. In addition, the tool was designed to have a flexible upgradability, i.e. no changes of the system programs are required when adding the new functions. The system functions are to design lightpaths and wavelengths allocated to ROADMs for the lightpaths required to groom given traffic. The tool also can search possible lightpath routes made by ROADMs with specified switch states, and output the total optical losses of the routes. By the tool implemented in one management and 3 calculation machines for the parallel processing, the total time to obtain the results for a 5-node IP-over-CWDM network was reduced down to 65 % of the total time by the tool with a single machine without parallel processing. The tool enables the network administrators to design and manage the lightpath reconfigurations effectively without errors by avoiding making unlinked lightpaths through routes with higher losses to connect nodes, before the reconfiguration.
PDF
