Chronic ischemic mitral regurgitation (MR) is a functional valvular disorder that occurs secondary to left ventricular remodeling due to old myocardial infarction or chronic myocardial ischemia. The presence of ischemic MR promotes further left ventricular remodeling and results in adverse outcomes. The goals of ischemic MR treatment are durable control of MR, left ventricular reverse remodeling, and improvement of the survival. However, surgical repair of the mitral valve alone may fail to achieve these goals. Furthermore, the mid-term mortality rate after endovascular repair remains high, although its survival benefit over medication was proven in a recent randomized trial. Therefore, to achieve these goals, treatment should target not only the mitral valve but also the left ventricle. In addition to maximally tolerated medical treatment and complete coronary revascularization, surgical procedures targeting the left ventricular should be added to mitral procedure to minimize the risk of adverse outcomes. Chordal preservation in the replacement of the mitral valve and subvalvular procedure is known to achieve left ventricular remodeling. Left ventriculoplasty can ameliorate adverse effects related to myocardial scarring. Despite the lack of evidence, such procedures have the potential to improve outcomes and may contribute to establishing an optimal treatment strategy. In this paper, the relationship between the pathological conditions of ischemic MR, predictors of adverse outcomes, and the effect of each treatment option was summarized by reviewing the literature.
Although saphenous vein grafts (SVGs) are used worldwide as bypass conduits, the long-term graft patency of an SVG is unfavorable compared to that of arterial grafts. Therefore, several attempts have been made to improve graft patency in SVGs. Souza et al. proposed a new SVG harvesting technique, called the “no-touch” SVG (NT-SVG), in which the SVG is harvested with perivascular fat and without high-pressure saline distension. This group reported an excellent rate of graft patency in a milestone randomized clinical trial comparing NT-SVG with conventional SVG (C-SVG). The 16-year patency rate of the NT-SVG was 83%, which was significantly higher than that of the C-SVG and comparable to the 16-year patency rate of 88% for left internal thoracic artery grafts. Several subsequent clinical and basic studies have shown the superiority of the NT-SVG over the C-SVG, and the use of the NT-SVG has become increasingly popular in Japan. However, delayed wound healing is more frequently reported at NT-SVG harvest sites than at C-SVG harvest sites. To overcome this limitation, endoscopic NT-SVG harvesting has been attempted recently. This article reviews recent studies related to NT-SVGs.
Postinfarction ventricular septal rupture (VSR) remains a critical problem with significant morbidity and mortality despite recent advances in cardiovascular therapeutics. To rescue patients with VSR, it is necessary to diagnose them promptly and correctly, manage them appropriately, and perform complete and lasting repair. This review of VSR is updated with a discussion of the epidemiology, pathogenesis, diagnosis, novel management, and repair procedures from our perspective. Surgical repair continues to be the main procedure of choice, although it is associated with high mortality in the acute phase. Transcatheter closure plays a limited role. Mechanical circulatory support (MCS) devices have shown some promise in delaying closure, but the best practice has yet to be determined. Secure surgical VSR closure before a patient develops cardiogenic shock continues to provide the best clinical outcomes.
Objective: The cutoff value on radiography for judging Achilles tendon xanthoma (ATX), one of the diagnostic criteria for familial hypercholesterolemia, was altered from 9 mm to 8/7.5 mm (men/women) in the new guidelines from the Japan Atherosclerosis Society. The present study investigated whether or not ATX newly identified by the revised criteria, i.e. Achilles tendon thickness (ATT) of ≥ 8 mm and < 9 mm in men, is associated with coronary lesion severity in premature coronary artery disease (CAD) patients. Methods: Eighty-seven male subjects with a history of acute coronary syndrome (ACS) under 60 years old and with a maximum ATT for the right and left sides of < 9 mm were enrolled. The severity of the coronary lesions was assessed using the SYNTAX score derived from coronary angiography at the onset of ACS. Results: Nine patients (10%) had a maximum ATT ≥ 8 mm (ATX group) among the present subjects. The SYNTAX score was significantly larger in the ATX group than in the non-ATX group (18.3 ± 9.8 vs. 12.3 ± 7.3, P = 0.028). The ATX group also had an increased body mass index (BMI) and C-reactive protein (CRP) level. In all subjects, the maximum ATT was positively correlated with the SYNTAX score (R = 0.337, P = 0.001). A multiple regression analysis revealed that the presence of ATX was significantly associated with the SYNTAX score, independent of confounding factors, including the BMI and CRP. Conclusions: This study demonstrated that ATX, even when mild, was associated with coronary lesion severity in premature CAD. ATX, based on new criteria, may be an independent predictor of CAD progression.
Objective: Lipoprotein(a) [Lp(a)] is an important causal factor of atherosclerosis and is heritable. The effect size of single nucleotide polymorphisms (SNPs) on Lp(a) among Japanese is not well understood. Materials and methods: Genotype imputation of common SNPs within the Lp(a) locus was performed based on SNP data used to perform direct genotyping with the Japonica Array® in 126 Japanese individuals with significantly high (< 70 mg/dL) or low (< 5 mg/dL) levels of Lp(a). In total, 187 SNPs with high imputation quality were identified at the LPA locus. The number of SNPs with high linkage disequilibrium was narrowed to 17. The chi-square test was used to identify associations between SNPs and Lp(a) levels, and a linear regression analysis was performed to evaluate the effect size of each SNP on Lp(a) levels. Furthermore, the polygenic risk score (PRS) of Lp(a) was calculated using statistically significant SNPs. Results: rs7454595, rs7765803, rs77182492, rs1652507, rs1321195 and rs74734070 were significantly associated with Lp(a) levels. However, the effect size of rs7454595, rs77182492, and rs74734070 on the levels in other ethnicities was unclear. Additionally, the absolute effect sizes of each SNP on Lp(a) levels ranged from 27.34 to 47.04 mg/dL per allele. The high Lp(a) group had a significantly higher PRS than the low Lp(a) group. A significant trend was observed in Lp(a) levels according to the PRS quartiles. Conclusions: There are shared and specific genetic characteristics that contribute to Lp levels among different ethnicities, and a few SNPs may partly explain the differences in Lp(a) levels among Japanese.