Recent studies have suggested an emerging link between obstructive sleep apnea (OSA) and atrial fibrillation (AF). Patients with OSA are less likely to remain in sinus rhythm after radiofrequency ...catheter ablation of AF.
To evaluate the efficacy of appropriate treatment with continuous positive airway pressure (CPAP) on recurrences of AF after ablation.
This study prospectively included 153 patients (128 men; 60 ± 9 years) who underwent extensive encircling pulmonary vein isolation for drug refractory AF. The standard overnight polysomnographic evaluation was performed 1 week after ablation, and the total duration and the number of central or obstructive sleep apnea or hypopnea episodes were examined.
Of 153 patients, 116 patients were identified as having OSA. Data regarding the use of CPAP and recurrences of AF were obtained in 82 patients. The remaining 34 patients with OSA were defined as the no-CPAP group. Polysomnography revealed no sleep-disordered breathing in 37 patients. During a mean follow-up period of 18.8 ± 10.3 months, 51 (33%) patients experienced AF recurrences after ablation. A Cox regression analysis revealed that the left atrial volume (hazard ratio HR 1.11; 95% confidence interval CI 1.01-1.23; P<.05), concomitant OSA (HR 2.61; 95% CI 1.12-6.09; P<.05), and usage of CPAP therapy (HR 0.41; 95% CI 0.22-0.76; P<.01) were associated with AF recurrences during the follow-up period.
Patients with untreated OSA have a higher recurrence of AF after ablation. Appropriate treatment with CPAP in patients with OSA is associated with a lower recurrence of AF.
Summary Background Staples have been widely used for skin closure after open gastrointestinal surgery. The potential advantages of subcuticular sutures compared with staples have not been assessed. ...We assessed the differences in the frequency of wound complications, including superficial incisional surgical site infection and hypertrophic scar formation, depending on whether subcuticular sutures or staples are used. Methods We did a multicentre, open-label, randomised controlled trial at 24 institutions between June 1, 2009, and Feb 28, 2012. Eligible patients aged 20 years or older, with adequate organ function and undergoing elective open upper or lower gastrointestinal surgery, were randomly assigned preoperatively to either staples or subcuticular sutures for skin closure. Randomisation was done via a computer-generated permuted-block sequence, and was stratified by institution, sex, and type of surgery (ie, upper or lower gastrointestinal surgery). Our primary endpoint was the incidence of wound complications within 30 days of surgery. Analysis was done by intention to treat. This study is registered with UMINCTR, UMIN000002480. Findings 1080 patients were enrolled and randomly assigned in a one to one ratio: 562 to subcuticular sutures and 518 to staples. 1072 were eligible for the primary endpoint and 1058 for the secondary endpoint. Of the 558 patients who received subcuticular sutures, 382 underwent upper gastrointestinal surgery and 176 underwent lower gastrointestinal surgery. Wound complications occurred in 47 of 558 patients (8·4%, 95% CI 6·3–11·0). Of the 514 who received staples, 413 underwent upper gastrointestinal surgery and 101 underwent lower gastrointestinal surgery. Wound complications occurred in 59 of 514 (11·5%, 95% CI 8·9–14·6). Overall, the rate of wound complications did not differ significantly between the subcuticular sutures and staples groups (odds ratio 0·709, 95% CI 0·474–1·062; p=0·12). Interpretation The efficacy of subcuticular sutures was not validated as an improvement over a standard procedure for skin closure to reduce the incidence of wound complications after open gastrointestinal surgery. Funding Johnson & Johnson.
Abstract Background The prevalence of Fabry disease (FD) in Japanese patients presenting with unexplained left ventricular hypertrophy (LVH) has remained unclear. Methods We measured plasma ...α-galactosidase A activity in 177 men with a diagnosis of hypertrophic cardiomyopathy (HCM) (maximum LV wall thickness ≥15 mm). Results Two patients (1.1%) showed very low α-galactosidase A activity 0.0 and 0.3 nmol/hr/ml (normal range: 3.6–17.6 nmol/hr/ml), and a clinical diagnosis of cardiac variant of FD was finally made. One patient was a 55-year-old man who came to our hospital because of abnormal results of electrocardiography and showed concentric LVH in echocardiography. A missense mutation, R112L, was identified. The other was a 74-year-old man who had been diagnosed with HCM at the age of 60 years in another hospital and was referred for evaluation of repeated hospitalization for heart failure. Although echocardiography revealed asymmetric septal hypertrophy (ASH) with interventricular septal wall thickness of 16 mm and posterior wall thickness of 11 mm and reduced LV ejection fraction with hypokinetic posterior wall motion, his echocardiographic findings at the initial diagnosis of HCM were not ASH but concentric LVH with normal LV systolic function. A splicing mutation, IVS4+919G>A, was identified. Conclusions The prevalence of FD in Japanese male patients with a clinical diagnosis of HCM was found to be 1.1%. These patients showed late onset and concentric LVH at initial presentation.
It remains unknown whether left ventricular (LV) reverse remodeling (LVRR) after therapy with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and β blockers is correlated ...with prognosis in patients with idiopathic dilated cardiomyopathy. Forty-two patients with idiopathic dilated cardiomyopathy treated with the therapy were studied. Complete left ventricular reverse remodeling was defined as LV end-diastolic dimension ≤55 mm and fractional shortening ≥25% at the last echocardiographic assessment. The incidence of complete LVRR was significantly higher in patients who survived than in those who died or underwent heart transplantation. Patients were divided into 3 groups: death or transplantation, alive with complete LVRR, and alive without complete LVRR. Although patients who died or underwent transplantation did not show any LV improvements, those with complete LVRR showed significant improvements at 1 to 6 months after starting the therapy. Patients without complete LVRR also showed small but significant improvements at 1 to 6 months. The decrease in LV end-systolic dimension from the initial value to that at 1 to 6 months was an independent determinant of future cardiac death or transplantation. In conclusion, complete LVRR is related to favorable prognosis in patients with idiopathic dilated cardiomyopathy. The extent of left ventricular reverse remodeling at 1 to 6 months after starting the therapy is predictive of long-term prognosis.
Background Ghrelin is a peptide hormone with pleiotropic functions including stimulation of growth hormone secretion and appetite, and its levels decrease after esophagectomy. The aim of this study ...was to evaluate whether exogenous ghrelin administration can meliorate the postoperative decrease of oral food intake and body weight, which are serious complications after esophagectomy. Methods This prospective randomized, placebo-controlled, clinical trial assigned a total of 20 patients with thoracic esophageal cancer who underwent radical operation into either a ghrelin ( n = 10) or placebo ( n = 10) group. Synthetic human ghrelin (3 μg/kg) or 0.9% saline placebo was administered intravenously twice daily for 10 days from the day after the start of food intake. The primary end point was calories of food intake. Comparison of appetite and changes in weight and body composition were also made between the 2 groups. Results Intake of food calories was greater in ghrelin group than placebo group (mean 874 vs 605 kcal per day; P = .015). The appetite score tended to be greater in ghrelin group than placebo group ( P = .094). Loss of weight was less in ghrelin group (–1% vs –3%; P = .019) and this attenuation was due largely to a decrease of lean body weight loss (0% vs –4%; P = .012). No side effects were observed in either groups. Conclusion These preliminary results suggest that administration of ghrelin after esophagectomy increased oral food intake and attenuated weight loss together with maintenance of lean body weight.
In addition to sudden death, heart failure and stroke due to atrial fibrillation are important in patients with hypertrophic cardiomyopathy (HCM). The aim of the present study was to determine ...whether Doppler tissue imaging findings and plasma B-type natriuretic peptide (BNP) levels, which are widely used for risk stratification in several cardiovascular diseases, are useful for risk stratification in patients with HCM in a regional cohort.
One hundred thirty patients (82 men; mean age, 60 ± 16 years) with HCM were enrolled in this study.
Twenty end points were observed during a mean follow-up period of 3.7 ± 1.7 years. Septal E/e' ratios and BNP levels in patients with events were higher than those in patients without events (17.4 ± 6.3 vs 10.6 ± 4.3, P < .0001, and 441 ± 304 vs 202 ± 174 pg/mL, P < .0001, respectively). By multivariate logistic regression analysis, a high septal E/e' ratio, in addition to a history of syncope and documentation of atrial fibrillation, was a significant predictor of combined end points. In contrast, plasma BNP levels were not a significant predictor of combined end points.
Assessment by Doppler tissue imaging is useful for further risk stratification of patients with HCM.
Optimal coronary reflow is the critical key issue to ameliorate clinical outcomes in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction (Shock-STEMI). We ...investigated our hypothesis that pre-percutaneous coronary intervention (PCI) procedural coronary thrombectomy may provide clinical advantages to attempt optimal coronary reflow in patients with Shock-STEMI. Of 7,650 patients with acute myocardial infarction registered in the Tokyo CCU Network Scientific Council from January 2009 to December 2011, a total of 180 consecutive patients (144 men, 68 ± 13 years) with Shock-STEMI who showed pre-PCI procedural Thrombolysis in Myocardial Infarction flow grade 0 (absent initial coronary flow) were recruited. Achievements of post-PCI procedural Thrombolysis in Myocardial Infarction flow grade 3 (optimal coronary reflow) and also in-hospital mortality were evaluated in those in accordance with and without coronary thrombectomy. Coronary thrombectomy was performed in 128 patients with Shock-STEMI (71% of all). Overall in-hospital mortality was 41% and that in anterior Shock-STEMI with a necessity of mechanical circulatory support increased by 59% (i.e., profound shock). Coronary thrombectomy did not affect any improvements in the achievement of optimal coronary reflow (65% vs 58%, p = 0.368) and in-hospital mortality (42% vs 37%, p = 0.484) in these patients. Even when focused on 76 patients with profound shock, neither an achievement of optimal coronary reflow (56% vs 47%, p = 0.518) nor in-hospital mortality (58% vs 65%, p = 0.601) were different between with and without coronary thrombectomy. Multivariate logistic analysis did not demonstrate any association of coronary thrombectomy (p = 0.798), left main Shock-STEMI (p = 0.258), and use of mechanical circulatory support (p = 0.119) except a concentration of hemoglobin (for each 1 g/dl increase, odds ratio 1.247, 95% confidence interval 1.035 to 1.531, p = 0.019) with optimal coronary reflow. In conclusion, pre-PCI procedural coronary thrombectomy may have serious limitations on attempting optimal coronary reflow that indicates a necessity of promising strategies for this critical illness.
Summary Objectives Hypertrophic cardiomyopathy (HCM) is a primary myocardial disorder with a broad spectrum of clinical features. Although gender may be one of the important modifying factors in HCM, ...there has been little information on gender differences. Methods We investigated gender-specific differences in the clinical features of HCM in a community-based Japanese population. We established cardiomyopathy registration in Kochi Prefecture named Kochi RYOMA study consisting of 9 hospitals as an unselected regional Japanese population. Results 261 patients with diagnosis of HCM were registered. At registration, 88 patients (34%) were women. Female patients were more frequently diagnosed as having HCM at ≥65 years (41% versus 27%) and had a higher ratio of familial HCM (35% versus 19%). More female patients had diagnosis of HCM due to cardiac symptoms (64% versus 40%) and were symptomatic both at diagnosis and at registration. Although the prevalence of atrial fibrillation was not different between males and females, embolic events occurred less frequently in female patients at registration than in male patients (2% versus 10%). In female patients, there were more obstructive HCM patients and fewer patients with apical HCM. Left ventricular and left atrial diameters were smaller and fractional shortening was higher in females than in males. Conclusions The manifestations of HCM in unselected Japanese patients differed in men and women, which suggest that hormonal, social, and genetic factors may influence the clinical presentation of HCM.
Background and Purpose Preoperative T staging demands high accuracy, because it greatly influences subsequent therapies in advanced gastric cancer. Patients and Methods 616 patients with gastric ...cancer underwent multi-detector row computed tomography (MDCT) before operation. The results were compared with operative and pathologic findings. Especially, we evaluated the correlations among the diagnostic accuracy of T staging and various clinicopathologic parameters by focusing on 276 patients who had detectable lesions by MDCT. Results The overall diagnostic accuracy of preoperative T staging by MDCT was 90.9% (560/616). For each pathologic T stage, the accuracy was 95% for pT1, 76% for pT2-3, 92% for pT4a, and 75% for pT4b, respectively. Among the 276 patients, 239 (87%) were correctly staged by MDCT whereas 29 (11%) and 8 (3%) were over- or under-staged, respectively. Antral tumors ( P = .045), and Borrmann type 1 tumors ( P = .0001) were incorrectly T staged by MDCT, whereas differentiated type tumors tended to be over-staged. All patients with positive cytology ( n = 12 cases) and peritoneal metastasis ( n = 7 cases) diagnosed at laparotomy had been diagnosed as T4a or deeper by MDCT. The 5-year overall survival rates classified by preoperative T staging by MDCT (T1/T2-3/T4a/T4b) were 100%, 89%, 59%, and 31%, respectively, whereas those for each pT stage were 100%, 84%, 59%, and 19%. Conclusion Preoperative T staging of gastric cancer by MDCT is highly accurate and could contribute to treatment strategies, particularly in advanced disease.
Abstract Background A significant problem to be solved for patients after liver transplantation (LT) is malnutrition with anorexia in the early posttransplant period. We hypothesized that this ...problem was due to the change in ghrelin metabolism during LT. The aim of this study was to examine the balance of acyl ghrelin (AG) and desacyl ghrelin and the dependence of the regulation mechanism on hepatic-related enzymes in patients during LT. Materials and methods AG, desacyl ghrelin, and acyl/total ghrelin (A/T) concentrations in blood samples were measured in 15 patients with liver failure (LF), 15 patients after LT, and 10 controls. The correlations between the participants' ghrelin profiles and hepatic function–related data, including liver enzymes, were evaluated. In vitro assays using synthetic AG for assessment of deacylation activity in serum were performed. Results AG and A/T ratio were significantly higher in the LF patients than the patients after LT and controls (AG: 25.9 ± 12.6 versus 16.4 ± 12.6 and 9.8 ± 7.6 fmol/mL, P < 0.05; A/T ratio: 17.4 ± 4.1 versus 12.2 ± 5.5 and 11.8% ± 5.9%, P < 0.05). The serum cholinesterase level was inversely correlated with AG and A/T ratio ( P < 0.01). In vitro assays showed that deacylation activity was significantly lower in patients with LF than controls (10.5% versus 42.4%, 90 min; P < 0.01). Degradation of AG was partially suppressed by a cholinesterase inhibitor. Conclusions Deacylation activity was lower in LF patients, which could cause elevation of AG levels. Serum cholinesterase may be responsible for deacylation in humans.
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