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Against the background of these remarkable developments, the guidelines needed to undergo many changes and revisions. [...]the format has been revised again to include cardiac implantable electronic devices and catheter ablation therapies. [...]prevention of systemic embolism using a left atrial appendage closure (LAAC) device is being established as a breakthrough treatment for AF patients who have difficulty in continuing anticoagulation therapy. Because early implantable cardioverter-defibrillators (ICDs) were highly invasive owing to the requirement for a thoracotomy, the indications for this treatment were highly limited. In 2004, cardiac resynchronization therapy (CRT) became available for patients with impaired cardiac function, and the usefulness of this treatment has been verified. especially in heart failure patients with complete left bundle branch block in Japan. Because patients with heart failure have a high risk of sudden death, an ICD with a biventricular pacing function (CRT defibrillator [CRT-D]) was also developed and approved in 2006.

Background Klippel-Trenaunay-Weber syndrome (KTWS) is a rare congenital malformation. Although there have been few reports on anaesthetic management of patients with KTWS, there is a lack of data on anaesthetic management for abdominal aortic aneurysm (AAA) surgeries in these patients. Case presentation A 74-year-old man (height, 160 cm and body weight, 51.5 kg) with KTWS was scheduled for AAA replacement. Abdominal computed tomography (CT) showed prominent tortuosity below the abdominal aorta with an infrarenal abdominal aortic aneurysm, right common iliac artery aneurysm, and right external iliac artery aneurysm. Moreover, a remarkably noted arteriovenous fistula had developed between the aneurysm and peripheral artery. General anaesthesia was induced. Furthermore, a central venous catheter and an 8.5 French sheath in the left internal jugular vein were inserted. During the operation, bleeding from a collateral vessel in the cross-clamped aorta led the surgeon to decide to perform aneurysmorrhaphy. Intraoperatively, blood loss was 1500 ml, and 20 units of red blood cell concentrate were used. Conclusions Regarding AAA procedures in patients with KTWS, aortic cross-clamping may not sufficiently intercept blood flow due to collateral vessels. In these patients, the anaesthesiologist must be prepared to transfuse blood more rapidly and frequently than during normal AAA procedures.

Background Recent developments in surgical devices, including left atrial appendage closure, have enabled surgeons to perform aggressive operations for atrial fibrillation (AF). However, the outcomes of AF surgery in emergent cases have not been extensively studied. Objective and methods The present study aimed to investigate the effectiveness of AF surgery in emergency surgery cases associated with cardiovascular events. We enrolled 18 patients who underwent various types of AF surgery due to emergencies, including acute aortic dissection ( n  = 6), acute myocardial infarction ( n  = 5), bleeding due to perforation from radiofrequency catheter ablation ( n  = 4), acute mitral regurgitation ( n  = 2), and cardiac tumor ( n  = 1). Four and ten patients underwent the full maze procedure and pulmonary vein isolation, respectively. Ganglionated plexi ablation was also performed in three patients as part of a combined procedure. The left atrial appendage was solely closed in four patients. Results There was no surgical mortality or major adverse cardiac and cerebrovascular events in our patient series. The rates of freedom of recurrence of AF or atrial tachycardia at 1 and 3 years were 92.9% and 82.5%, respectively. After a mean follow-up period of 46.7 ± 25.8 months, no thromboembolism events were observed in the patients. Furthermore, no cardiovascular death was recorded. Conclusion The surgical procedures for AF are safe and effective in cases requiring emergency surgery.

Background Atrial fibrillation (AF) is frequently seen in patients with a volume-loaded left atrium (LA) such as mitral valve regurgitation (MR). Previous animal models have incomplete relevance to human AF associated with MR. Methods A novel experimental model with a combination of volume loading of LA by creating a shunt from the subclavian artery to pulmonary artery and electrical remodeling induced by continuous rapid LA pacing was designed and the electrophysiological effects were examined in 10 canines. Five weeks after the shunt surgery, the entire atrial epicardium was mapped during sustained AF with form-fitted electrode patches with 246 bipolar electrodes and a three-dimensional dynamic mapping system to characterize the induced AF. Results Three animals died of severe heart failure and pacing failure occurred in one. Remaining six animals were subjected to the analysis. The LA diameter increased progressively after the shunt surgery. Sustained AF was induced after 3 weeks of continuous rapid LA pacing in all animals. The activation maps revealed repetitive focal activations arising from the pulmonary veins, right or left atrial regions, and reentrant activations in the RA, which patterns of atrial activations are the same as those seen in human AF. Conclusion The animal model with a combination of LA volume load and electrical remodeling was relevant to human AF associated with LA volume load. Studies using the present model may provide further knowledges of AF and may be useful in examining the effects of pharmacological and non-pharmacological therapies.

Background: To describe an aortic arch incision and closure technique (AICT) for proximal fixation of a frozen elephant trunk (FET) and to report early outcomes. Methods: We retrospectively reviewed 15 consecutive patients who underwent distal arch repair with an FET using AICT (mean age 77 ± 7 years; 14 men). Indications were distal arch aneurysm (n = 12), acute Stanford type B dissection (n = 2), and distal arch enlargement after thoracic endovascular aortic repair (n = 1). Under circulatory arrest, an oblique arch aortotomy was created, the FET was deployed antegrade, trimmed, and sutured to the native aortic wall during simultaneous closure, allowing extended posterior fixation. Clinical outcomes and postoperative computed tomography were assessed. Results: No ischemic complications related to graft kinking or thrombosis, reoperation for bleeding, stroke, spinal cord ischemia, or organ failure occurred. One patient died of pneumonia on postoperative day 47 (6.7%). Cervical branch reconstruction was required in 12 patients (80%), whereas two patients with type III arch morphology and acute angulation were treated without debranching via a Zone 3 aortotomy. At a median follow-up of 29 months, no proximal endoleak was observed; one distal endoleak occurred without reintervention. Coronary bypass grafts remained patent in all patients with concomitant or prior CABG. Conclusions: AICT provided secure proximal FET fixation and arch closure while preserving the ascending aorta, offering an alternative to total arch replacement in selected distal arch pathologies.

Objective The benefit of adding ganglionated plexi ablation to the maze procedure remains controversial. This study aims to compare the outcomes of the maze procedure with and without ganglionated plexi ablation. Methods This multicenter randomized study included 74 patients with atrial fibrillation associated with structural heart disease. Patients were randomly allocated to the ganglionated plexi ablation group (maze with ganglionated plexi ablation) or the maze group (maze without ganglionated plexi ablation). The lesion sets in the maze procedure were unified in all patients. High-frequency stimulation was applied to clearly identify and perform ganglionated plexi ablation. Patients were followed up for at least 6 months. The primary endpoint was a recurrence of atrial fibrillation. Results The intention-to-treat analysis included 69 patients (34 in the ganglionated plexi ablation group and 35 in the maze group). No surgical mortality was observed in either group. After a mean follow-up period of 16.3 ± 7.9 months, 86.8% of patients in the ganglionated plexi ablation group and 91.4% of those in the maze group did not experience atrial fibrillation recurrence. Kaplan–Meier atrial fibrillation–free curves showed no significant difference between the two groups ( P  = .685). Cox proportional hazards regression analysis indicated that left atrial dimension was the only risk factor for atrial fibrillation recurrence (hazard ratio: 1.106, 95% confidence interval 1.017–1.024, P  = .019). Conclusion The addition of ganglionated plexi ablation to the maze procedure does not improve early outcome when treating atrial fibrillation associated with structural heart disease.

Introduction Adrenal myelolipoma is a benign adrenal tumor that is typically asymptomatic and is rarely associated with hemorrhage or rupture. Here, we present a case of adrenal myelolipoma with spontaneous hemorrhage. Case presentation A 72‐year‐old man with a history of obesity and hypertension visited the Department of Emergency Medicine with a sudden onset of severe left flank pain. Enhanced computed tomography showed a left adrenal tumor containing a fat component with a focus of contrast medium visualized extravasation. The patient was diagnosed with adrenal myelolipoma with spontaneous hemorrhage. Selective adrenal arterial embolization was performed to manage the severe pain, and the condition immediately improved. Four months later, laparoscopic left adrenalectomy was performed via a transperitoneal approach. Histopathological examination confirmed the diagnosis of adrenal myelolipoma. Conclusion Urgent transarterial embolization followed by elective laparoscopic adrenalectomy is a safe and minimally invasive treatment option for managing adrenal myelolipomas with hemorrhage.

Background The Fontan procedure has improved the prognosis of patients with a functional single ventricle; however, late complications—including Fontan-associated liver disease (FALD)—have surfaced as clinical concerns. FALD with signs of portal hypertension has been defined as advanced FALD (aFALD) due to its poor prognosis. Recently, noninvasive tests (NITs) have been found to predict liver fibrosis in FALD. Liver stiffness measurement excluding strain elastography (SE) was affected by hepatic congestion; however, to our knowledge, not many studies have evaluated the SE-derived Liver Fibrosis Index (LFI). This study aimed to determine the efficacy of NITs, especially LFI, for discriminating aFALD. Methods In this retrospective study, 46 Japanese patients with FALD were included and classified into the aFALD (33 patients; 22 males and 11 females; median age: 28.0 years) and non-aFALD (13 patients; seven males and six females; median age: 22.0 years) groups based on the presence/absence of signs of portal hypertension. Results The platelet count, FIB-4 index, Forns index, and LFI differed significantly between the two groups and demonstrated moderate accuracy for discriminating aFALD. The shear wave velocity (Vs) measured by Shear Wave Elastography (SWE) did not differ significantly between the two groups. The cut-off value of platelet counts below 185 × 10 3 /μL had 78.8% sensitivity and 92.3% specificity. While 25/26 (96.2%) of the patients with FALD who had platelet counts below 185 × 10 3 /μL were aFALD, 8/20 (40.0%) of the patients with FALD who had platelet counts above below 185 × 10 3 /μL were also aFALD, indicating the need for additional markers. In the patients with FALD who had platelet counts above 185 × 10 3 /μL, only SE indicated moderate diagnostic accuracy, and the LFI cut-off value of 2.21 had 100% sensitivity and 75.0% specificity. Conclusions Using a two-step approach, discriminating aFALD with platelet counts below 185 × 10 3 /μL by platelets alone, and for those with higher platelet counts, requiring LFI > 2.21 could discriminate aFALD with high accuracy. Early detection of aFALD and early intervention, including testing for aFALD, may lead to an improved prognosis of aFALD.

Background Intracardiac thrombus is relatively rare in patients with coronavirus disease 2019 (COVID-19). However, if it occurs, thrombotic complications are likely to develop. In this case, we performed a successful thrombectomy on a patient who developed left ventricular thrombus after COVID-19 infection without complications. Case presentation A 52-year-old man sought medical care due to fever, dyspnea, and abnormalities in the taste and smell that persisted for 2 weeks. The patient was diagnosed with COVID-19 and was treated with remdesivir, baricitinib, and heparin. Three weeks after hospitalization, electrocardiogram revealed angina pectoris, and cardiac catherization showed left anterior descending coronary artery stenosis. In addition, global hypokinesis and a thrombus at the left ventricular apex were observed on echocardiography. Left ventricular reconstruction concomitant with coronary artery bypass grafting was performed. A thrombus in the left ventricle was resected via left apical ventriculotomy, and the bovine pericardium was covered and sutured on the infarction site to exclude it. The patient was extubated a day after surgery and was transferred to another hospital for recuperation after 20 days. He did not present with complications. Conclusions Thrombotic events could be prevented via thrombectomy with left ventricular reconstruction using an intraventricular patch to exclude the residual thrombus.

Menthol is thought to stimulate lacrimation via activation of cold-sensitive primary afferent neurons in the cornea. We evaluated a warm compress containing menthol as a potential treatment for dry eye by examining its effects on the tear film in healthy subjects ( n  = 20) and dry eye patients ( n  = 35). Disposable eyelid-warming steamers that either did (MH) or did not (HO) contain menthol were applied to one eye of each subject either once only for 10 min or repeatedly over 2 weeks. Single application of MH significantly increased tear meniscus volume ( P  = 8.6 × 10 −5 , P  = 1.3 × 10 −5 ) and tear film breakup time ( P  = 0.006, P  = 0.002) as well as improved meibum condition in healthy subjects and dry eye patients, respectively. Repeated application of MH significantly increased tear meniscus volume ( P  = 0.004, P  = 1.7 × 10 −4 ) and tear film breakup time ( P  = 0.037, P  = 0.010) in healthy subjects and dry eye patients, respectively. Repeated application of MH thus induced persistent increases in tear fluid volume and tear film stability in dry eye patients, suggesting that repeated use of a warm compress containing menthol is a potential novel treatment for dry eye disease.