Coronary Vein Research Articles

Leptin Expression in Human Epicardial Adipose Tissue Is Associated with Local Coronary Atherosclerosis.

BackgroundLeptin is an adipokine related to overweight and cardiovascular diseases. However, the leptin expression level in epicardial adipose tissue (EAT) of humans and its association with coronary atherosclerosis has never been investigated.Material/MethodsPatients receiving cardiac surgery were divided into a coronary artery disease group (CAD group) and a non-CAD group (NCAD group). Blood samples from coronary vein, biopsies of subcutaneous adipose tissue (SAT), and EAT were acquired during the surgery. Serum leptin level and leptin level in EAT and SAT were tested with ELISA, quantitative PCR, and immunohistochemistry and were compared between the CAD group and NCAD group, as well as between stenosis and non-stenosis subgroups. Logistic regression analysis was performed to explore the risk factors for coronary artery stenosis.ResultsNo statistically significant differences were found in demographic and clinical data between groups (all P>0.05). Serum leptin concentration and leptin expression in EAT and SAT of the CAD group were much higher in than in the NCAD group (all P<0.05). In subgroup analysis, there was no difference in serum leptin and expression in SAT of stenosis and non-stenosis patients (All P>0.05). The leptin expression level in EAT of stenosis patients was significantly higher than in non-stenosis patients (P=0.0431). By multivariate logistic regression analysis, we demonstrated that leptin expression level in EAT was an independent risk factor for coronary artery stenosis [OR=1.09, 95%CI (1.01±1.18), P=0.031].ConclusionsLeptin expression in EAT and SAT were both increased for CAD patients. Leptin expression in EAT was an independent risk factor for coronary atherosclerosis in the adjacent artery, while leptin in SAT was not associated.

Coronary venoplasty during cardiac resynchronization therapy device implantations: Acute results and clinical outcomes

Optimal left ventricular (LV) lead placement improves response to cardiac resynchronization therapy (CRT) but can be hindered by unfavorable venous anatomy. Interventional procedures in the coronary veins have been described with promising short-term outcomes. The purpose of this study was to establish the safety and efficacy of percutaneous coronary venoplasty (PCV) during CRT implantation and assess medium-term lead performances and clinical outcomes against matched controls not requiring PCV. Each consecutive PCV case was matched according to age, gender, and bundle branch morphology to 2 controls from a large prospective registry of CRT recipients. Demographics, procedural success, lead performance, and response to CRT were tracked using a comprehensive electronic medical records system. Of 422 consecutive CRT recipients treated between 2012 to 2018, 29 patients (6.9%; mean age 65.7 ± 10.7 years; 7 female; 17 ischemic cardiomyopathy; 22 left bundle branch block) required PCV, which was successful in 21 cases (72%). Target veins measuring 1.1 ± 0.6 mm were dilated by noncompliant balloons with mean diameter 2.8 ± 0.5 mm. No complications occurred. Fluoroscopic and procedural durations were longer in the PCV group (P <.01) Over mean follow-up of 33.0 ± 25.0 months, no differences in lead performance, CRT response, or 2-year survival were observed compared to the control group. PCV during CRT device implant is typically successful, safe and associated with long-term clinical outcomes comparable to patients who did not need PCV. This is an important technique to optimize LV lead placement and maximize CRT response.

Post mortem coronary angiography in a preemie heart \u2013 a case report

BackgroundPostmortem coronary angiography has been used in forensic medicine for several decades but its use has never been documented in neonatal hearts. The objective of this case is to report the use of postmortem coronary angiography as a diagnostic modality for neonates suspected to have complex congenital heart anomalies.Case presentationA 36-week-old female infant required extracorporeal membranous oxygenation for persistent hypotension on day 1 of life. A congenital echocardiogram (ECHO) on day 3 of life revealed multiple anomalous vascular structures within the interventricular septum. The infant passed away on day 4 of life after the parents elected to withdraw support. A consent for autopsy was taken from the parents and a postmortem coronary angiography was performed. The coronary vessels were injected with Iodixanol contrast via a 24 G angiocath under fluoroscopy. The anomalous septal vessels were identified as dilated coronary artery and vein. No other anomalies were identified.ConclusionPostmortem coronary angiography complements other imaging procedures in understanding the nature of some complex congenital heart defects and in determining the cause of death in such neonates.

Left ventricular pacing in patients with preexisting tricuspid valve disease.

BackgroundConventional right ventricular (RV) pacing is increasingly recognised to cause tricuspid valve (TV) injury or dysfunction, in part due to the need to pass the lead through the valve. This may be especially problematic in patients with preexisting TV disease or prior TV surgery. An alternative in this situation is to implant a left ventricular (LV) lead instead of ventricular pacing.MethodsWe performed a single‐center retrospective analysis of 26 patients with tricuspid valve surgery/disease who received a LV pacing lead in the coronary veins to avoid crossing the tricuspid valve, with or without a right atrial lead. A matched control population was obtained from patients receiving conventional right ventricular pacing and outcomes were compared. Main outcomes of interest were lead stability, electrical lead parameters and change in echocardiographic parameters such as left ventricular ejection fraction (LVEF) during long‐term follow‐up.ResultsSuccessful left ventricular pacing was established in 25 out of the 26 cases with one case converted to a RV lead due to lead dislodgement. During the 2.96 ± 1.0 year follow‐up, 24 of 25 (96.0%) leads were functional with stable pacing and sensing parameters, and 1 of 25 (4.0%) was extracted for due to device infection following an episode of thrombophlebitis.ConclusionWe conclude that in patients with existing tricuspid valve disease or surgery, ventricular pacing via the coronary veins is a feasible, safe, and reliable alternative to right ventricular pacing.

Unmodified autologous stem cells at point of care for chronic myocardial infarction.

BACKGROUNDNumerous studies investigated cell-based therapies for myocardial infarction (MI). The conflicting results of these studies have established the need for developing innovative approaches for applying cell-based therapy for MI. Experimental studies on animal models demonstrated the potential of fresh, uncultured, unmodified, autologous adipose-derived regenerative cells (UA-ADRCs) for treating acute MI. In contrast, studies on the treatment of chronic MI (CMI; > 4 wk post-MI) with UA-ADRCs have not been published so far. Among several methods for delivering cells to the myocardium, retrograde delivery into a temporarily blocked coronary vein has recently been demonstrated as an effective option.AIMTo test the hypothesis that in experimentally-induced chronic myocardial infarction (CMI; > 4 wk post-MI) in pigs, retrograde delivery of fresh, uncultured, unmodified, autologous adipose-derived regenerative cells (UA-ADRCs) into a temporarily blocked coronary vein improves cardiac function and structure.METHODSThe left anterior descending (LAD) coronary artery of pigs was blocked for 180 min at time point T0. Then, either 18 × 106 UA-ADRCs prepared at “point of care” or saline as control were retrogradely delivered via an over-the-wire balloon catheter placed in the temporarily blocked LAD vein 4 wk after T0 (T1). Effects of cells or saline were assessed by cardiac magnetic resonance (CMR) imaging, late gadolinium enhancement CMR imaging, and post mortem histologic analysis 10 wk after T0 (T2).RESULTSUnlike the delivery of saline, delivery of UA-ADRCs demonstrated statistically significant improvements in cardiac function and structure at T2 compared to T1 (all values given as mean ± SE): Increased mean LVEF (UA-ADRCs group: 34.3% ± 2.9% at T1 vs 40.4 ± 2.6% at T2, P = 0.037; saline group: 37.8% ± 2.6% at T1 vs 36.2% ± 2.4% at T2, P > 0.999), increased mean cardiac output (UA-ADRCs group: 2.7 ± 0.2 L/min at T1 vs 3.8 ± 0.2 L/min at T2, P = 0.002; saline group: 3.4 ± 0.3 L/min at T1 vs 3.6 ± 0.3 L/min at T2, P = 0.798), increased mean mass of the left ventricle (UA-ADRCs group: 55.3 ± 5.0 g at T1 vs 71.3 ± 4.5 g at T2, P < 0.001; saline group: 63.2 ± 3.4 g at T1 vs 68.4 ± 4.0 g at T2, P = 0.321) and reduced mean relative amount of scar volume of the left ventricular wall (UA-ADRCs group: 20.9% ± 2.3% at T1 vs 16.6% ± 1.2% at T2, P = 0.042; saline group: 17.6% ± 1.4% at T1 vs 22.7% ± 1.8% at T2, P = 0.022).CONCLUSIONRetrograde cell delivery of UA-ADRCs in a porcine model for the study of CMI significantly improved myocardial function, increased myocardial mass and reduced the formation of scar tissue.

Vascular injury and anatomy during laparoscopy - assisted distal gastrectomy with D2 lymphadenectomy for gastric cancer

Objective: To evaluate the incidence of intraoperative vascular injury (IVI) and associated anatomical features during laparoscopy - assisted distal gastrectomy (LADG) with D2 lymphadenectomy for gastric cancer. Methods: A descriptive cohort study was performed. Clinical data and operational videos of 278 consecutive gastric cancer patients who underwent LADG with D2 lymphadenectomy for gastric cancer at Department of General Surgery of Nanfang Hospital between January 2010 and December 2017 were retrospectively analyzed. IVI and vascular anatomy during lymphadenectomy were observed and recorded in the following four scenes: scene I: No. 4sb and No.4d of lower left (tail of pancreas) area; scene II: No.6 of lower right (subpyloric) area; scene III: No.5 and No.12a of upper right (suprapyloric) area; scene IV: No. 7, No. 8a, No. 9, No. 11p of central area posterior to the gastric body. IVI was defined as the injury of main perigastric vessel requiring additional procedure for hemostasis such as electrocauterization, gauze compression, clipping or suture. Results: Among 278 patients, 125 (45.0%) had IVI. Two cases of IVI required conversion to open operation and the injuried vascular was left gastric artery (LGA) and right gastric artery (RGA), respectively. Higher incidence of IVI was found in scene II (92/278, 33.1%) and scene IV(39/278, 14.0%). More common IVI was observed in right gastroepiploic vein (RGeV, 57/278, 20.5%) and left gastric vein (LGV, 33/278, 11.9%). The right gastroepiploic vessels were observed in all 278 patients, including 3 (1.1%) cases with 2 RGeVs, and 2 cases with 2 right gastroepiploic arteries (RGeA). RGA was observed clearly in 265 (95.3%) patients, whose ramification pattern was as follows: from proper hepatic artery (PHA, 223/265, 84.2%), from gastroduodenal artery (GDA, 16/265, 6.0%), from left hepatic artery (LHA, 12/265,4.5%), from the crossing of PHA and GDA (8/265, 3.0%), and 6 (2.3%) patients with 2 RGAs simultaneously from PHA and GDA, respectively. The most common injury of RGA (4/12) occurred in LHA. Excluding 2 cases of conversion to open surgery due to intraoperative hemorrhage, among 276 patients, LGV was observed in 270 patients (97.1%), whose drainage pattern was as follows: into the portal vein (PV, 148/270, 54.8%), into the spleen vein (SV, 56/270, 20.7%), into the junction of these two veins (52/270, 19.3%), into left portal vein (LPV, 8/270, 3.0%), meanwhile 6 patients had 2 LGVs simultaneously, including LGVs of 5 cases into PV and SV, and of 1 case into PV-SV junction and SV. The most common IVI was found in those patients with two LGVs (4/6). Conclusions: IVI during LADG with D2 lymphadenectomy is common. The highest risk of IVI is found in scene II and scene IV. Attentions should be paid to anatomic variation of vessels, especially the RGeV, LGV and RGA.

Five-year follow-up of transvenous and epicardial left ventricular leads: experience with more than 1000 leads.

Transvenous coronary sinus leads are considered to be the gold standard for cardiac resynchronization therapy (CRT). However, in patients with abnormal coronary vein anatomy, the epicardial leads can be an alternative. Data comparing durability and performance of these 2 lead types are limited. In order to provide clarity, we investigated patients receiving CRT system in our centre. One thousand and fifty-three consecutive patients scheduled for CRT implantation were retrospectively analysed. From these, 895 received transvenous coronary sinus and 158 epicardial left ventricular (LV) leads. Lead-specific as well as LV functional parameters have been evaluated in 60 months' follow-up. Technical characteristics (pacing threshold, impedance and sensing) of both lead types remained stable during the whole observation period. Whereas an early revision (<6 month) was noted in 5.4% of transvenous leads, no reintervention has been necessary for epicardial leads. During the 5-year observation period, a lead revisions rate of 10.2% for transvenous leads and 1.9% for epicardial leads were detected. Regarding CRT efficacy, excellent results were achieved for both electrode types. In both groups, a statistically significant reduction of New York Heart Association class (2.85-2.13 and 2.96-2.09), increase in left ventricular ejection fraction (24.6-32.6% and 27.2-34.6%), reduction of left ventricular end-systolic diameter/left ventricular end-diastolic diameter and reduction in degree of mitral valve insufficiency could be observed over the time. Our data demonstrate safety and functional efficacy of both transvenous and epicardial leads. Moreover, in long-term follow-up, a commendable durability and performance were found for both lead types. Thus, epicardial leads represent a good alternative when transvenous implantation fails.

An image fusion tool for echo-guided left ventricular lead placement in cardiac resynchronization therapy: Performance and workflow integration analysis.

The response rate to cardiac resynchronization therapy (CRT) may be improved if echocardiographic-derived parameters are used to guide the left ventricular (LV) lead deployment. Tools to visually integrate deformation imaging and fluoroscopy to take advantage of the combined information are lacking. An image fusion tool for echo-guided LV lead placement in CRT was developed. A personalized average 3D cardiac model aided visualization of patient-specific LV function in fluoroscopy. A set of coronary venography-derived landmarks facilitated registration of the 3D model with fluoroscopy into a single multimodality image. The fusion was both performed and analyzed retrospectively in 30 cases. Baseline time-to-peak values from echocardiography speckle-tracking radial strain traces were color-coded onto the fused LV. LV segments with suspected scar tissue were excluded by cardiac magnetic resonance imaging. The postoperative augmented image was used to investigate: (a) registration accuracy and (b) agreement between LV pacing lead location, echo-defined target segments, and CRT response. Registration time (264±25seconds) and accuracy (4.3±2.3mm) were found clinically acceptable. A good agreement between pacing location and echo-suggested segments was found in 20 (out of 21) CRT responders. Perioperative integration of the proposed workflow was successfully tested in 2 patients. No additional radiation, compared with the existing workflow, was required. The fusion tool facilitates understanding of the spatial relationship between the coronary veins and the LV function and may help targeted LV lead delivery.

P3122Complete versus culprit-vessel only revascularization for patients with acute coronary syndromes and multivessel disease

Abstract Background Recent randomized clinical trials have suggested that complete revascularization (CR) instead of culprit-vessel only revascularization (CVO) strategies may take a stand in the optimal management of patients admitted for acute myocardial infarction (AMI) with multivessel (MV) disease undergoing primary percutaneous coronary intervention (P-PCI). However, despite the 2017 ST-elevation acute coronary syndrome (STEMI) guidelines update with a new class of recommendation for CR, it remains controversial whether this strategy leads to better outcomes. Purpose To compare CR versus CV strategies during hospitalization in patients presenting with AMI with multivessel disease at P-PCI. Methods We analyzed data from all patients admitted with non-ST acute myocardial infarction (NSTEMI) and STEMI in a portuguese coronary care unit (CCU), between 2007 and 2016. We then evaluated potential differences of CR versus CVO with PCI during hospitalization in AMI patients with multivessel disease, defined by at least 2 different diseased main coronary vessels, saphenous vein or mammary artery conduits. We used 1:1 ratio propensity score matching to study the impact of CR on patient mortality and adjusted data for relevant risk factors at admission time. Results A total of 4758 patients were admitted for AMI, 2690 NSTEMI (56.5%) and 2068 STEMI (43.5%). Access to PCI records was possible in 3162 (66.5%) patients, of which 1707 (54%) underwent CR versus 1455 (46%) who underwent CVO. CVO patients were older (67.9±11.8 vs. 63.5±13.1 years, p&lt;0.001), more diabetic (56.5% vs. 47.1%, p&lt;0.001), hypertensive (78.4% vs. 72.2%, p&lt;0.001), dyslipidemic (82.1% vs. 75%, p&lt;0.001), had greater GRACE score at admission (mean score 143.4±37.2 vs. 131.2±131.2, p&lt;0.001), had more severe coronary disease (mean number of diseased vessels – 2.56±0.6 vs. 2.18±0.4, p&lt;0.004), reached higher Killip class (mean – 1.42±0.9 vs. 1.26±0.7, p&lt;0.001) and had lower left ventricular ejection fraction (48.07±11.6 vs. 51.25±10.5, p&lt;0.001). No significant differences were found in peak troponin-I release between CR and CV (44.7±69 vs. 46.9±76, respectively, p=0.468). After propensity matching, we obtained 130 CR and 133 CVO patients. In this cohort all-cause mortality was lower in CR group at 6-month (RR 0.262, CI 95% 0.071–0.962, p=0.031) and 1-year (RR 0.340, CI 95% 0.119–0.973, p=0.036) follow-up. When comparing STEMI versus NSTEMI all-cause mortality was nonsignificantly lower in CR (RR 0.394 vs. 0.226, p=0.12 vs. p=0.16). Conclusions In patients presenting with AMI and MV disease, CR strategy during hospitalization leads to greater 6-month and 1-year survival when compared with CVO strategy. Despite not having found significant differences when STEMI was directly compared to NSTEMI, we believe this was due to the great loss of patient numbers after propensity matching, requiring larger trials to prove the effect.

P5685Abnormal anatomy of the coronary sinus in congenitally corrected transposition of the great arteries (double discordance): a pitfall for transvenous cardiac resynchronization therapy?

Abstract Background Congenitally corrected transposition of the great arteries (ccTGA) or double discordance is a rare congenital heart defect associating discordant atrioventricular and ventriculoarterial connections. Late prognosis depends on the progressive failure of the systemic right ventricle (RV). A possible cause for systemic RV dysfunction could be ventricular asynchrony. Cardiac resynchronization therapy (CRT) may thus be indicated in some cases. However, the cardiologists may experience some problems with the coronary sinus (CS) when implanting a 3-lead CRT transvenous system in these patients. Aim of the study To evaluate the anatomy of the CS and cardiac veins in specimens with ccTGA, in order to assess the feasibility of transvenous CRT. Material and methods Among the anatomic collection of the French Centre of Reference for complex CHD, 51 heart specimens had ccTGA with 2 ventricles. There were 33 post-natal and 18 fetal hearts. Hearts were reviewed with special attention paid to the course and drainage of the CS and cardiac veins. Segmental anatomy, location of the ventricular septal defect (VSD), status of the pulmonary outflow tract and anomalies of the atrioventricular valves were reviewed. Results Segmental anatomy was {S,L,L} in 46/51 hearts, {S,L,D} in 2 and {I,D,D} in 3. There was a VSD in 40 (outlet in 25, inlet in 11, both in 2, muscular in 2), pulmonary atresia in 13, subpulmonary stenosis in 6, abnormal tricuspid valve in 20/48 including Ebstein anomaly in 6, straddling in 9 (3 had replacement). The CS was always located behind the morphologically left atrium (LA). However, its anatomy was normal, with normal drainage into the morphologically right atrium, in only 25/51 (49% of cases). The CS was of reduced length with normal orifice in 17. Orifice was atretic with normal size CS in 2, and CS was completely absent in 6 with direct drainage of coronary veins into the LA. At least 1 available vein was found in all cases with patent CS orifice. Conclusion CS in ccTGA is always located behind the morphologically LA. However, its anatomy is abnormal in half of cases. The most frequent anomalies are reduced length (33%) and absent CS or atretic orifice (15.5%). The anatomy of CS should therefore be assessed by imaging techniques (multislice CT imaging or CS venography) before considering transvenous CRT in these patients.

P4503A multi-site coronary vein sampling study on cardiac troponin T degradation in non-ST-elevation myocardial infarction

Abstract Background High-sensitivity cardiac troponin (hs-cTn) assays have reduced specificity for myocardial infarction (MI). In conditions other than MI, cardiac troponin T (cTnT) elevations have been attributed to small cTnT fragments. In search of improved cTnT assay specificity for MI, determination of the in-vivo molecular appearance of cTnT during MI is pivotal. Purpose To determine cTnT composition close to its site of release and during the course of MI by multi-site coronary venous system (CVS) and peripheral sampling. Methods Lithium-heparinized (LH) plasma and serum samples were obtained from multiple CVS locations in NSTEMI patients. Additionally, samples were drawn from a peripheral artery and vein followed by collections at 6- and 12 hours post-catheterization. cTnT concentrations were measured using the hs-cTnT immunoassay (Roche). The molecular cTnT composition was determined by gel filtration chromatography and Western blotting in an early and late presenting patient. Results CVS hs-cTnT concentrations were 28% higher than in the peripheral artery sample (n=71, p&lt;0.001). In contrast to LH plasma, serum caused pre-analytical cTn T-I-C complex disintegration and cTnT degradation. CVS samples demonstrated presence of cTn T-I-C complex, free intact cTnT, and 29 kDa and 15–18 kDa cTnT fragments in higher absolute concentrations than measured peripherally. While the proportion of cTn T-I-C complex decreased and disappeared over time, 15–18 kDa cTnT fragments increased. Moreover, cTn T-I-C complex was more prominent in the early versus the late presenting patient. Central illustration Conclusions In NSTEMI, cTnT is released as a combination of cTn T-I-C complex, free intact cTnT and multiple cTnT fragments. Over time, the composition of observed cTnT forms changes due to in-vivo degradation. These findings serve as a stepping stone to improve diagnostic accuracy of the hs-cTnT assay for MI.

Acute and Long-Term Outcomes of Transvenous Cardiac Pacing Device Implantation in Patients With Congenital Heart Disease.

Background: Little is known about the acute/long-term outcomes of implantation of cardiac implantable electronic devices (CIED) using a transvenous approach for patients with congenital heart disease (CHD).Methods and Results: We retrospectively investigated the acute/long-term results and complications associated with transvenous CIED implantation in 140 patients with CHD. We implanted 77 pacemakers, 51 implantable cardioverter defibrillators (ICD), and 12 cardiac resynchronization therapy (CRT) devices. Although we successfully implanted pacemakers and ICD in all patients, we could not place a coronary sinus (CS) lead in 25% of the patients requiring CRT devices due to coronary vein anomalies associated with corrected transposition of the great arteries (cTGA). Overall complication rate, lead failure rate, and incidence of device infection were 16%, 9%, and 0.7%, respectively. There was no significant difference in overall complication rates between the simple (n=22) and complex CHD (n=118) groups (14% vs. 16%). The 10-year lead survival for the ICD leads (77%) was significantly lower than for the pacemaker leads (91%, P=0.0065).Conclusions: The outcomes of transvenous CIED in patients with CHD seemed acceptable, although there was a relatively high incidence of complications. CS lead placement for cTGA may be hindered by coronary vein anomalies. Lead survival tended to be lower for ICD than for pacemakers in these patients.

Serum nutritional markers and faecal elastase-1 testing in biliopancreatic cancer patients

Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.

Galectin-1 is a novel therapeutic target and diagnostic/prognostic biomarker for pancreatic cancer

Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.

Rapid on-site glucometry of cystic fluid is a feasible and accurate method for the diagnosis of mucinous cystic pancreatic lesions

Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.

Results of portosystemic shunts during extended pancreatic resections.

Patients with borderline resectable pancreatic cancer are increasingly explored after neoadjuvant treatment protocols. A complete resection, then, frequently includes the resection of the mesentericoportal axis. Portosystemic shunting for advanced tumours with infiltration of the splenic vein or cavernous transformation of the portal vein can enable complete tumour resection and prevent portovenous congestion of the intestine. The aim of this study was to report the results of this technique for selected patients. Patients operated for pancreatic cancer at our department between September 2012 and December 2017 using intraoperative portosystemic shunting were included in this retrospective analysis. Some 11 patients with pancreatectomy and simultaneous portosystemic shunting were included. The median age was 65.1years. A distal splenorenal shunt and a temporary mesocaval shunt were accomplished in 5 and 4 cases, respectively. Two patients were operated using persistent mesocaval shunts (from the coronary, splenic or inferior mesenteric veins). The median operating time was 9.43h. All but one patient were resected with tumour-negative resection margins; 5 patients had relevant complicated postoperative courses. There was one case of in-hospital mortality but no further 30- or 90-day mortality or graft-associated complications. Five patients were alive after a median follow-up of 24.6months. The median postoperative survival was 12months. Portosystemic shunting at the time of extended pancreatectomy is technically challenging but feasible and enables complete tumour resection in cases in which standard vascular reconstruction is limited by cavernous transformation or to prevent sinistral portal hypertension with acceptable morbidity in selected cases. Considering the limited overall survival, the potential individual patient benefit needs to be weighed against the considerable morbidity of advanced tumour resections.

Bipolar radiofrequency ablation delivered from coronary veins and adjacent endocardium for treatment of refractory left ventricular summit arrhythmias.

Radiofrequency catheter ablation (RFCA) of premature ventricular complexes (PVC) and ventricular tachycardia (VT) can be an effective method of treatment. However, when arrhythmia originates from the left ventricular summit (LVS), an ablation performed with conventional unipolar energy sources can be challenging and may require alternative approaches. Bipolar RFCA from coronary veins and an adjacent endocardium in cases of refractory PVC/VT has not yet been studied. We retrospectively analysed cases of consecutive patients who underwent bipolar ablation in whom conventional unipolar ablation of LVS PVC/VT and antiarrhythmic drugs failed to abolish arrhythmia. Bipolar RFCA was delivered from the earliest PVC/VT activation located in the coronary venous circulation and opposite LV endocardial sites. A total number of 4 patients (1 female, age 55 ± 10years) underwent bipolar ablation of LVS from coronary veins and an adjacent endocardium. Bipolar RFCA led to acute elimination of PVC/VT in all patients. A mean bipolar RFCA time was 244 ± 15s. There were no complications during procedures and all antiarrhythmic drugs were discontinued. A follow-up lasted 15 ± 4months; there was no VT recurrence and the mean 83 ± 27% PVC burden reduction (24250 ± 1372 vs. 3000 ± 3600 PVC/d; p = 0.0228) was achieved. All patients remained symptom-free. Bipolar RFCA from coronary veins and an opposite endocardium can be used for safe and successful treatment of PVC/VT originating from a deep LV summit.

Abstract 562: Comprehensive Arteriovenous Metabolomics in the Human Heart

Introduction: Despite broad interest in the role of metabolism in the pathogenesis of heart failure, a definitive account of fuel use by the beating human heart in situ is lacking. We therefore determined the uptake and release of over 270 metabolites by simultaneous sampling of arterial, coronary sinus, and femoral venous blood in 100 patients. Methods: We enrolled 100 patients (60% male, 12% diabetic, age = 63.6 +/- 13.5 years, BMI = 29.75 +/- 6.1, EF = 57.14 +/- 6.48) undergoing ablation of atrial fibrillation. We used liquid chromatography-mass spectrometry to quantify over 270 metabolites in plasma from coronary sinus, femoral vein, and arterial blood. We also measured O 2 and CO 2 concentration, as well as atrial pressure. Results: We detected uptake or release of 77 metabolites by the heart and 136 metabolites across the leg (p &lt;0.05 after Benjamini-Hochberg correction). We determined the cardiac extraction of all major fuel sources, including 29 fatty acids, 11 amino acids, lactate, acetoacetate, and 3-hydroxybutyrate. Several patterns emerge: first, while the leg extracts glucose (FV/A = 0.95, q = 4.7x10-14) and releases lactate (FV/A = 1.11, q = 2.87x10-14), the heart extracts lactate (CS/A = 0.95, q = 3.77x10-9) and neither extracts nor secretes glucose. Second, while the leg releases nearly all fatty acid and amino acid species, the heart consumes most fatty acids and certain non-essential amino acids. Third, extraction of unsaturated acylcarnitines correlates with left atrial pressure (p&lt;0.01). Finally, we find a significant positive correlation between myocardial O2 consumption and extraction of ketones (p &lt; 0.01), but not other major cardiac fuels. Conclusion: We present the most comprehensive study to date of metabolite use and secretion by the human heart. We find the heart to be an avid consumer of fatty acids and ketone bodies, but less so of glucose and essential amino acids. Consumption of ketones increases with O2 consumption, suggesting that ketones may be a preferential fuel source under high work loads. Extraction of certain acylcarnitines increases with left atrial pressure, indicating metabolic reprogramming under high filling pressures. In summary, we provide the first comprehensive model of fuel use by the beating human heart in situ.

Blood levels of adiponectin and IL-1Ra could facilitate earlier detection of PDAC by distinguishing individuals with type 3c diabetes from those with type 2 diabetes

Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.

The antagonistic effect of L-tryptophan, its metabolite and AhR receptor blocker on the course of the apoptotic pathway in human pancreatic carcinoma cells

Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.