Diaphragmatic hernia developing after hepatectomy is rare. A 51-year-old female patient who had undergone right hepatectomy via a thoraco-laparotomy presented 9 months later complaining of upper ...abdominal pain and nausea. An abdominal CT revealed a diaphragmatic hernia and bowel obstruction, and we performed laparoscopic surgery. The cause of the herniation was determined as failure of the sutures of the diaphragm. The hernia orifice was repaired with a mesh coated with an adhesion inhibitor. Thus, laparoscopic surgery is a valid treatment option for diaphragmatic hernia developing after liver resection. As incarcerated diaphragmatic hernias could prove fatal, the possibility of diaphragmatic hernias developing as a late complication after liver resection should be borne in mind.
Objectives: This study aimed to compare open stoma (OS) creation with laparoscopic stoma (LS) creation considering the operation time, blood loss, time of oral intake, and complications. We also ...compared multiport LS and single-incision laparoscopic stoma (SILS) creation. Methods: We reviewed the demographic data, diagnosis, indications, operation time, blood loss, time of oral intake, operative procedure, and complications of 50 patients who underwent stoma creation between April 2014 and April 2016. Results: The mean blood loss was significantly lower in the LS group (7.85±18.4 ml) than in the OS group (38.1±73.2 ml; P=0.02). There were no statistical differences between the groups in terms of the operation time (LS, 72.1±32.7 min; OS, 61.2±31.2 min; P=0.23) or time of oral intake (LS, 1.0±0 days; OS, 1.91±2.71 days; P=0.17). Peristomal skin problems occurred in 11 patients (47.8%) in the OS group and 5 patients (18.5%) in the LS group. There were no statistically significant differences between the SILS and multiport LS groups, considering the operation time, amount of bleeding, and time of oral intake. Conclusions: LS is comparable with OS in terms of operation time and time of oral intake and may cause lesser blood loss. Considering its advantages, LS is a useful approach for patients requiring biopsies or intra-abdominal inspection. SILS is a minimally invasive technique, suitable for patients in whom the stoma site is preoperatively decided.
•Plaque erosion is the second major pathological substrate of acute coronary syndrome (ACS).•Plaque erosion is characterized with intact fibrous cap on optical coherence tomography.•Patients with low ...low-density lipoprotein cholesterol showed more intact fibrous cap at the culprit lesion.•Intact fibrous cap plaque might be the major cause of ACS after failed primary prevention.
There remains a residual risk for acute myocardial infarction (AMI) even with low low-density lipoprotein cholesterol (LDL-C) levels. This study aimed to characterize the culprit lesion morphology of AMI by optical coherence tomography (OCT) in patients with low LDL-C.
Four-hundred and nine culprit lesions of 409 patients with their first presentation of AMI imaged by OCT were investigated. OCT analysis included the presence of plaque rupture and thin-capped fibroatheroma (TCFA). Fibrous cap thickness and lipid length were also measured. Intravascular ultrasound (IVUS) was performed in 368 (90.0%) patients. OCT and IVUS findings were compared between patients with LDL-C < 100 mg/dl (lower-LDL group) and those with LDL ≥ 100 mg/dl (higher-LDL group).
Lower-LDL group included 93 (22.7%) patients. Plaque rupture (54.8% vs. 68.7%, p = 0.018) and TCFA (39.8% vs. 54.6%, p = 0.013) were less frequently observed in lower-LDL than in higher-LDL. Fibrous cap was thicker 73 (59–109) µm vs. 63 (57–83) µm, p = 0.028 and lipid length was smaller 5.4 (2.3–9.9) mm vs. 7.1 (4.1–10.5) mm, p = 0.012 in lower-LDL than in higher-LDL. There were no significant differences in IVUS parameters including plaque burden or remodeling index between the two groups.
Patients with lower LDL-C showed more prevalent intact fibrous cap and less vulnerable features in the culprit lesions, which may suggest the need for exploring a specific strategy for the prevention of plaque erosion in low LDL-C subjects.
Background
The reported incidence of phrenic nerve injury (PNI) varies owing to different definitions, balloon generations, balloon size, freezing regimen, and protective maneuvers. We evaluated the ...incidence, predictors, and outcome of PNI during cryoballoon pulmonary vein isolation in a large population.
Methods and Results
Five hundred fifty atrial fibrillation patients underwent pulmonary vein isolation using one 28‐mm second‐generation cryoballoon and single 3‐minute freeze strategy under diaphragmatic compound motor action potential (CMAP) monitoring. A total of 34 (6.2%) patients experienced PNI during the right superior and inferior pulmonary vein ablation in 30 and 4 patients, respectively. Applications were interrupted using double‐stop techniques after 136 104–158 second applications, and a pulmonary vein isolation was already achieved in all but one case. The baseline CMAP amplitude and timing of deflation (CMAPdef) were 0.75±0.30 and 0.17±0.17 mV, respectively. Persistent atrial fibrillation, larger right superior pulmonary vein ostia, and deeper balloon positions were associated with higher incidences of PNI. The CMAPdef predicted a PNI recovery delay, and the best cutoff value for predicting PNI recovery by the next day was 0.20 mV (sensitivity 57.1%, specificity 100%). Among 6 patients undergoing second procedures 8.5 (6.7–15.0) months later, the right superior pulmonary vein was durable in 3 with >120 second applications. Despite active balloon deflation, no significant pulmonary vein stenosis was observed in 15 right superior pulmonary veins evaluated 6 (5–9) months later. No patients had symptoms, and the PNI recovered 1 day and 1 month postprocedure in 21 and 4 patients, respectively.
Conclusions
PNI resulting from cryoballoon ablation was reversible. The double‐stop technique is safe, and immediate active deflation following a CMAP decrease appears to be essential for faster PNI recovery.
Abstract
In the presence of functionally significant epicardial lesions, microvascular resistance reserve (MRR) calculation needs incorporation of collateral flow. Coronary fractional flow reserve ...(FFR
cor
) requiring coronary wedge pressure (P
w
), which is an essential part of the true MRR calculation, is reportedly estimated by myocardial FFR (FFR
myo
) not requiring P
w
measurement. We sought to find an equation to calculate MRR without the need for P
w
. Furthermore, we assessed changes in MRR after percutaneous coronary intervention (PCI). An equation to estimate FFR
cor
was developed from a cohort of 230 patients who underwent physiological measurements and PCI. Corrected MRR was calculated using this equation and compared with true MRR in 115 patients of the different set of the validation cohort. True MRR was calculated using FFR
cor
. FFR
cor
and FFR
myo
showed a strong linear relationship (
r
2
= 0.86) and an equation was FFR
cor
= 1.36 × FFR
myo
– 0.34. This equation provided no significant difference between corrected MRR and true MRR in the validation cohort. Pre‐PCI lower coronary flow reserve and higher index of microcirculatory resistance were independent predictors of pre‐PCI decreased true MRR. True MRR significantly decreased after PCI. In conclusion, MRR can be accurately corrected using an equation for FFR
cor
estimation without P
w
.
This study sought to assess the predictors of coronary computed tomography angiographic findings for non-infarct-related (non-IR) territory unrecognized myocardial infarction (UMI) in patients with a ...first episode of non-ST-elevation acute coronary syndrome (NSTE-ACS).
UMI detected by cardiac magnetic resonance imaging (CMR) is associated with adverse outcomes in patients with both acute coronary syndrome and chronic coronary syndrome. However, the association between the presence of UMI and coronary computed tomography angiographic (CCTA) findings remains unknown.
We investigated 158 patients with a first clinical episode of NSTE-ACS, who underwent pre-PCI 320-slice CCTA and uncomplicated urgent percutaneous coronary intervention (PCI) within 48 h of admission. In these patients, post-PCI CMR was performed within 30 days from urgent PCI and before non-IR lesion staged PCI. UMI was assessed using late gadolinium enhancement (LGE)-CMR by identifying regions of hyperenhancement with an ischemic distribution pattern in non-IR territories (non-IR UMI). CCTA analysis included qualitative and quantitative assessments of the culprit segment, Agatston score, mean peri-coronary fat attenuation index (FAI), epicardial fat volume (EFV) and epicardial fat attenuation (EFA).
Non-IR UMI was detected in 30 vessel territories (9.7%, 30/308 vessels) of 28 patients (17.7%, 28/158 patients). The presence of low-attenuation plaque, spotty calcification, napkin ring sign, and positive remodeling was not significantly different between vessels with and without subtended non-IR UMI. Agatston score >30.0 (OR: 8.39, 95% confidence interval (CI): 2.17 to 32.45,
= 0.002), mean FAI >-64.3 (OR: 3.23, 95% CI: 1.34 to 7.81,
= 0.009), and stenosis severity (OR: 1.04, 95% CI: 1.02 to 1.06,
< 0.001) were independently associated with non-IR UMI. Neither EFV (
= 0.340) nor EFA (
= 0.700) was associated with non-IR UMI.
The prevalence of non-IR UMI was 17.7 % in patients with first NSTE-ACS presentation. Agatston score, mean FAI, and coronary stenosis severity were independent CCTA predictors of the presence of non-IR UMI. The integrated CCTA assessment may help identify the presence of non-IR UMI before urgent PCI.
A 69-year-old woman underwent abdominoperineal resection for a gastrointestinal stromal tumor (GIST) of the rectum 15 years ago. She received adjuvant chemotherapy for 8 years. Seven years later, ...abdominal computed tomography revealed a soft-tissue shadow in the left lower abdomen, and fluorodeoxyglucose uptake was observed at the same site on positron emission tomography. The recurrence of GIST was suspected, and laparoscopic resection was performed. Laparoscopy showed that the tumor was located at the retroperitoneum near to the descending colon and invaded the left ovarian vessels. It also made contact with the left ureter; however, lighted ureteral catheters enabled us to identify and preserve the left ureter. An immunohistochemical examination revealed the recurrence of GIST. Recurrence may become apparent 15 years or more after GIST surgery, and, thus, a long-term follow-up is required. Lighted ureteral catheters were useful for identifying the ureter and preventing ureteral injury in a recurrent case suspected of invading the ureter.
Background
Coronary flow capacity (CFC) is a potentially important physiologic marker of ischemia for guiding percutaneous coronary intervention (PCI) indication, while the changes through PCI have ...not been investigated.
Objectives
To assess the determinants and prognostic implication of delta CFC, defined as the change in the CFC status following PCI.
Materials and Methods
From a single-center registry, a total of 450 patients with chronic coronary syndrome (CCS) who underwent fractional flow reserve (FFR)-guided PCI with pre-/post-PCI invasive coronary physiological assessments were included. Associations between PCI-related changes in thermodilution method-derived CFC categories and incident target vessel failure (TVF) were assessed.
Results
The mean (
SD
) age was 67.1 (10.0) years and there were 75 (16.7%) women. Compared with patients showing no change in CFC categories after PCI, patients with category worsened, +1, +2, and +3 category improved had the hazard ratio (95%
CI
) for incident TVF of 2.27 (0.95, 5.43), 0.85 (0.33, 2.22), 0.45 (0.12, 1.63), and 0.14 (0.016, 1.30), respectively (
p
for linear trends = 0.0051). After adjustment for confounders, one additional change in CFC status was associated with 0.61 (0.45, 0.83) times the hazard of TVF. CFC changes were largely predicted by the pre-PCI CFC status.
Conclusion
Coronary flow capacity changes following PCI, which was largely determined by the pre-PCI CFC status, were associated with the lower risk of incident TVF in patients with CCS who underwent PCI. The CFC changes provide a mechanistic explanation on potential favorable effect of PCI on reducing vessel-oriented outcome in lesions with reduced CFC and low FFR.
Pathological studies have reported that patients with acute coronary syndrome (ACS) may have different plaque morphologies at culprit lesions, and one of the underlying mechanisms for ACS is plaque ...erosion. However, the morphological features of plaque erosion obtained by multiple intracoronary imaging modalities have not been fully elucidated.
We experienced two cases with ACS of culprit lesions exhibiting optical coherence tomography (OCT)-defined plaque erosion. Additional examinations using near-infrared spectroscopy (NIRS)-intravascular ultrasound and coronary angioscopy suggested the presence of two distinct phenotypes of plaque erosion. These two types of erosion differ in the extent of NIRS-derived lipid core burden and coronary angioscopy-derived luminal surface colour.
OCT-defined plaque erosion may not be the unique entity but have at least two distinct plaque morphologies, and NIRS and/or coronary angioscopy may provide incremental ability of discriminating these plaque phenotypes classified as plaque erosion by OCT.
Near-infrared spectroscopy (NIRS) provides the localization of lipid-rich components in coronary plaques. However, morphological features in NIRS-detected lipid-rich plaques (LRP) are unclear.
A ...total of 140
culprit lesions in 140 patients with the acute coronary syndrome (ACS) who underwent NIRS and optical coherence tomography (OCT) examinations for the culprit lesions at the time of percutaneous coronary interventions were investigated. We defined a NIRS-LRP as a lesion with a maximum lipid core burden index of 4 mm LCBI
> 500 in the culprit plaque. Clinical demographics, angiographic, and OCT findings were compared between the patients with NIRS-LRP (
= 54) vs. those without NIRS-LRP (
= 86). Uni- and multivariable logistic regression analyses were performed to examine the independent OCT morphological predictors for NIRS-LRP.
Clinical demographics showed no significant differences between the two groups. The angiographic minimum lumen diameter was smaller in the NIRS-LRP group than in the non- NIRS-LRP group. In OCT analysis, the minimum flow area was smaller; lipid angle, lipid length, the prevalence of thin-cap fibroatheroma, and cholesterol crystals were greater in the NIRS-LRP group than in the non-NIRS-LRP group. Plaque rupture and thrombi were more frequent in the NIRS-LRP group, albeit not significant. In a multivariable logistic regression analysis, presence of thin-cap fibroatheroma odds ratio (OR): 2.56; 95% CI: 1.12 to 5.84;
= 0.03 and cholesterol crystals (OR: 2.90; 95% CI: 1.20 to 6.99;
= 0.02) were independently predictive of NIRS-LRP.
In ACS culprit lesions, OCT-detected thin-cap fibroatheroma and cholesterol crystals rather than plaque rupture and thrombi were closely associated with a great lipid-core burden.
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