Acute kidney injury (AKI) is relatively common after cardiothoracic surgery for type A acute aortic dissection (TA-AAD) and increases mortality. We investigated the incidence and risk factors for AKI ...in patients with TA-AAD and its impact on their outcomes. The records of 375 consecutive patients who underwent surgical treatment for TA-AAD from October 2007 to March 2013 were analyzed retrospectively. We defined AKI using the Kidney Disease Improving Global Outcomes criteria, which are based on serum creatinine concentration or glomerular filtration rate. We used Kaplan-Meier methods and multivariate Cox proportional hazards regression to assess the impact of AKI on both mortality and major adverse cardiovascular and cerebrovascular events. We also examined the association between risk factors and AKI using logistic regression modeling. Postoperative AKI was observed in 165 patients (44.0%). The overall 30-day and mid- to long-term mortality was 1.6% and 8.8%, respectively. Mortality and major adverse cardiovascular and cerebrovascular events correlated significantly with the severity of AKI, and multivariate analysis showed that AKI stage 3 (the most sever stage) was an independent risk factor for mortality (hazard ratio 6.83, 95% confidence interval 2.52 to 18.52) after adjustment for important confounding factors. Extracorporeal circulation time, body mass index, perioperative peak serum C-reactive protein concentration, renal malperfusion, and perioperative sepsis were found to be risk factors for AKI. In conclusion, AKI was common in patients who underwent surgery for type A acute aortic dissection. The severity of AKI strongly influences patient outcomes, so it should be recognized promptly and treated aggressively when possible.
Abstract Background The efficacy and safety of transcatheter aortic valve implantation (TAVI) in Asian populations were unknown. The purpose of this study was to compare directly the clinical ...outcomes of the first Japanese trial and a European single-center experience after TAVI. Methods and results Between April 2010 and October 2011, 64 patients were included in the PREVAIL JAPAN multicenter trial which was set up to evaluate the safety and efficacy of the Edwards SAPIEN XT™ (Edwards Lifesciences, Irvine, CA, USA) in high-risk Japanese patients with severe aortic stenosis. Between March 2010 and January 2012, 237 consecutive patients treated with TAVI using the Edwards SAPIEN XT™ prosthesis at Institut Cardiovasculaire Paris Sud were prospectively included in the Massy cohort. We compared the clinical outcomes of these two cohorts. Patients were of similar age (83.4 ± 6.6 years vs. 84.5 ± 6.1 years, p = 0.25), but logistic EuroSCORE was higher in the Massy cohort (20.2 ± 11.7% vs. 15.6 ± 8.0%, p < 0.01). Body surface area was smaller in the PREVAIL JAPAN cohort (1.41 ± 0.14 m2 vs. 1.72 ± 0.18 m2 ; p < 0.01) as was the annulus diameter (20.4 ± 1.46 mm vs. 22.0 ± 1.84 mm, p < 0.01). The transfemoral approach was used in 57.8% in the Japanese cohort vs. 51.5% in the Massy cohort. Device success was similar (89.1% vs. 94.1%, p = 0.21, respectively), as well as 30-day and 6-month survival rates (92.2% vs. 90.7% and 89.1% vs. 83.1%, p = 0.71 and p = 0.25, respectively). The incidence of major vascular complications was not significantly different between the two groups (9.4% vs. 5.9%, p = 0.23, respectively). A higher post-procedural mean pressure gradient was observed in the PREVAIL JAPAN cohort (12.7 ± 11.4 mmHg vs. 10.1 ± 3.6 mmHg, p = 0.01), but satisfactory improvement in 6-month functional status was obtained in both cohorts (76.5% vs. 77.2%, p = 0.91). Conclusions Clinical outcomes after TAVI in the patients included in the PREVAIL JAPAN trial were acceptable and as safe as that of a single-center European cohort.
Previous reports have shown that serum elastin fragments (SEFs) may be a useful biomarker for the diagnosis of an acute aortic dissection (AAD). However, because the reference interval of SEFs has ...not been established, it has not been determined whether SEFs are really useful for the diagnosis of AAD. The purpose of this study was to determine the usefulness of measuring SEFs for the diagnosis of AAD. A total of 42 consecutive patients aged 68 ± 18 years who were diagnosed with an AAD were studied. Patient background and SEF levels were examined on admission. SEF levels were also measured in patients undergoing a medical examination (n = 531, age 54 ± 17 years) to compare with those with an AAD. In the control group, SEF levels increased with age ( R = 0.725, p <0.001). Then, we defined the upper limit of the reference interval of SEF levels as the 97.5th percentile of control SEF grouped by decade of life from the sixth to ninth decade. The overall risk of AAD exceeding the upper limit of the reference interval at each decade was 10% (4 of 42). For patients in their 60s and 70s, median SEF levels in the AAD group (89 77 to 104, 93 60 to 123 ng/ml, respectively) were not significantly higher than those in the control group (79 68 to 92, 90 79 to 106 ng/ml, respectively; p = 0.081 and 0.990, respectively). Our data suggest that measuring SEF levels may not be useful in the diagnosis of an AAD as the upper limit of the reference interval of the SEF level was unexpectedly higher.
Abstract In spite of the increasing interest in palliative care for heart disease, data on the detailed methods of palliative care and its efficacy specifically in heart disease are still lacking. A ...structured PubMed literature review revealed no quality indicators of palliative care in heart disease. Therefore, we performed a narrative overview of the potential quality indicators in heart disease by reviewing previous literature concerning quality indicators in cancer patients. We summarize seven potential categories of quality indicators in heart disease: (1) presence and availability of a palliative care unit, palliative care team, and outpatient palliative care; (2) human resources such as number of skilled staff; (3) infrastructure; (4) presence and frequency of documentation or family survey; (5) patient-reported outcome measure (PROM) data and disease-specific patient quality of life such as The Kansas City Cardiomyopathy Questionnaire (KCCQ); (6) questionnaires and interviews about the quality of palliative care after death, including bereaved family surveys; and (7) admission-related outcomes such as place of death and intensive care unit length of stay. Although detailed measurements of palliative care quality have not been validated in heart disease, many indicators developed in cancer patients might also be applicable to heart disease. This new categorization might be useful to determine quality indicators in heart disease patients.
Abstract Background Several studies from Western countries have reported associations between cardiac troponin and B-type natriuretic peptide (BNP) levels and acute pulmonary embolism prognosis; ...however, the number of such reports from Asian countries, including Japan, is limited. Thus, we evaluated the relationship between blood biochemical findings and acute-phase pulmonary embolism prognosis in Japanese patients. Methods The subjects included 441 patients with acute pulmonary embolism (191 men, 250 women; average age, 65.8 ± 16.0 years) treated at Tokyo CCU Network Institutions from 2009 to 2011 and registered via survey forms. The association between blood biochemical findings at admission and 30-day mortality was investigated. Results The median BNP value was 186.5 pg/mL (25th to 75th interquartile range: 49.8–500 pg/mL) of 210 cases. No deaths were recorded among those with BNP levels <90 pg/mL ( n = 70), whereas significantly higher mortality (10 deaths/140 cases, 7.1%; p = 0.033) was observed among those with BNP levels ≥90 pg/mL. A qualitative cardiac troponin test was positive in 58 of the 204 cases (28.4%), with a significantly higher mortality incidence ( p = 0.017) among the troponin-positive cases 6 (10.3%) versus 3 (2.1%) deaths among the 146 troponin-negative cases. The overall mean blood glucose level at admission of 331 cases was 152.0 ± 74.0 mg/dL, and 30-day mortality significantly increased with blood glucose values ( p = 0.048). Conclusions Troponin, BNP, and blood glucose levels are useful prognostic biomarkers for acute pulmonary embolism in Japanese patients.
Although several studies have shown the relation between temperature/atmospheric pressure and pulmonary embolism (PE), their results are inconsistent. Furthermore, diurnal temperature range (DTR) and ...diurnal pressure range (DPR) were not fully evaluated for their associations with hospital admissions for PE. Study subjects comprised cases of 1,148 PE treated at institutions belonging to the Tokyo Cardiovascular Care Unit Network from January 2005 to December 2012. Patient data were combined with a variety of daily local climate parameters obtained from the Japan Meteorological Agency. Every 1°C increase in the DTR at lag0 corresponded to an increased relative risk of hospital admission for PE (odds ratio OR 1.036, 95% confidence interval CI 1.003 to 1.070). In the cooler season (November to April), an increase of 1 hPa (barometric pressure) in the DPR at lag4 and lag5 was associated with an increased relative risk of hospital admission for PE (OR 1.042, 95% CI 1.007 to 1.077 and OR 0.952, 95% CI 0.914 to 0.992, respectively). An increase in the PE hospitalization rate was seen only in the cool season. Using a metropolitan database, we showed that DTR and DPR have different impacts on hospital admissions for PE. In conclusion, we found that an increase in the DTR increases the PE hospitalization rate, especially during the cooler season. The impact of DTR and DPR on PE incidence and related hospitalizations needs to be further evaluated.
Abstract Objective To elucidate the current status of use of inferior vena cava filters (IVCFs) in cases of pulmonary embolism at institutions belonging to the Tokyo CCU Network. Methods We conducted ...a retrospective investigation of 832 consecutive cases of pulmonary embolism reported on survey forms to the Tokyo CCU Network between 2005 and 2010. Results Of 832 cases of pulmonary embolism, IVCFs were used in 338 (40.6%) and not used in 415 (49.9%). Their use was unclear in 79 (9.5%) cases. The use rate gradually increased each year from 2005 until 2008 but decreased from 2009 onward. Moreover, 68.9% of the IVCFs used in cases were non-permanent types. In terms of pulmonary embolism severity, the rate of use was 37.2% in non-massive cases, 49.4% in sub-massive cases, 46.9% in massive cases, and 31.9% in collapse cases. Thirty-day mortality in cases of collapse in which IVCFs were not used was extremely high at 75.8%, suggesting that in many cases, rapid deterioration may occur with insufficient time for IVCF insertion. The differences in IVCF usage rate among institutions were large in the range of 12.5–90% from 2005 to 2008, which slightly declined to the range of 25.0–72.2% from 2009 to 2010. Conclusions We elucidated the current IVCF use status in cases of pulmonary embolism at institutions belonging to the Tokyo CCU Network. Since the status of use differed among institutions, future studies of effective methods of use are required.
Abstract Background Acute heart failure (AHF) is one of the most frequently encountered cardiovascular conditions that can seriously affect the patient’s prognosis. However, the importance of early ...triage and treatment initiation in the setting of AHF has not been recognized. Methods and Results The Tokyo Cardiac Care Unit Network Database prospectively collected information of emergency admissions to acute cardiac care facilities in 2005–2007 from 67 participating hospitals in the Tokyo metropolitan area. We analyzed records of 1,218 AHF patients transported to medical centers via emergency medical services (EMS). AHF was defined as rapid onset or change in the signs and symptoms of heart failure, resulting in the need for urgent therapy. Patients with acute coronary syndrome were excluded from this analysis. Logistic regression analysis was performed to calculate the risk-adjusted in-hospital mortality. A majority of the patients were elderly (76.1 ± 11.5 years old) and male (54.1%). The overall in-hospital mortality rate was 6.0%. The median time interval between symptom onset and EMS arrival (response time) was 64 minutes (interquartile range IQR 26–205 minutes), and that between EMS arrival and ER arrival (transportation time) was 27 minutes (IQR 9–78 minutes). The risk-adjusted mortality increased with transportation time, but did not correlate with the response time. Those who took >45 minutes to arrive at the medical centers were at a higher risk for in-hospital mortality (odds ratio 2.24, 95% confidence interval 1.17–4.31; P = .015). Conclusions Transportation time correlated with risk-adjusted mortality, and steps should be taken to reduce the EMS transfer time to improve the outcome in AHF patients.
Abstract A 78-year-old woman complained of experiencing dyspnea (New York Heart Association II) and faintness. Echocardiography revealed she had asymmetric left ventricular hypertrophy, and a dynamic ...left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion of the mitral valve. It also revealed calcification of the noncoronary cusp and a high-flow velocity in the LVOT (6.3 m/s). The planimetry measurement with transesophageal echocardiography was 0.89 cm2 (aortic valve area/body surface area: 0.69 cm2 /m2 ). Later, she was diagnosed with hypertrophic obstructive cardiomyopathy (HOCM) and aortic stenosis (AS). However, during the catheterization, the transvalvular pressure gradient (PG) was only 25 mmHg. In order to solve this, we performed a percutaneous transluminal septal myocardial ablation. As a result, the PG of the LVOT decreased from 152 mmHg to 25 mmHg. We first thought that the LVOT obstruction had reduced the flow passing through the aortic valve, and restricted the motion of the aortic valve leaflets. We also considered the possibility that the aortic valve area had been underestimated. The hemodynamic study played an important role in the decision for the treatment plan. The present case was a combination of HOCM and “mild” AS. < Learning objective : We know that we can distinguish between a left ventricular outflow tract obstruction and aortic stenosis using continuous-wave Doppler according to the phase of the peak gradient. However, if both are present, it is uncertain whether we can distinguish between them. It is necessary to measure the subaortic pressure and flow passing through the aortic valve accurately by catheterization in order to know which is the chief pathology.>
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