Publications by authors named "Hirokazu Onishi"

25 Publications

  • Page 1 of 1

Resting echocardiographic predictors for true-severe aortic stenosis in patients with low-gradient severe aortic stenosis: A dobutamine stress echocardiography study.

Echocardiography 2021 Sep 23. Epub 2021 Sep 23.

Department of Cardiology, New Tokyo Hospital, Chiba, Japan.

Objective: Dobutamine stress echocardiography (DSE) is not always feasible in patients with low-gradient severe aortic stenosis (LG-SAS), and there are limited data available on the resting echocardiographic predictors for true-severe aortic stenosis (TSAS). This study investigated resting echocardiographic predictors for TSAS.

Methods: Clinical data of 106 LG-SAS patients who underwent DSE were retrospectively analyzed. LG-SAS was defined as an aortic valve area index (AVAi) < .6 cm /m , and a mean AV pressure gradient < 40 mm Hg. The velocity ratio (VR) was calculated as the peak left ventricular outflow tract velocity/peak AV velocity. TSAS was defined as a projected AVAi < .6 cm /m .

Results: The mean age was 79.3 ± 7.3 years, and 45 (42.5%) were men. The resting AV data were as follows: AVAi, .50 ± .07 cm /m ; mean AV pressure gradient, 23.0 ± 7.4 mm Hg; and VR, .25 ± .05. The projected AVAi was .58 ± .09 cm /m , and TSAS was documented in 65 (61.3%) patients. In multivariate analysis, the independent predictors of TSAS were AVAi (p = 0.012) and VR (p = 0.004) with respective best cut-off values of .52 cm /m and .25 on receiver-operating characteristic curve analysis. According to incremental numbers of the predictors, correct classification percentages of TSAS significantly increased with the Cochran-Armitage trend test (16.2% in no predictors, 65.2% in one predictor, and 95.7 % in two predictors; p < 0.001).

Conclusions: Resting AVAi and VR were independent predictors of TSAS in LG-SAS patients. The true severity might be predictable using the combination of resting parameters.
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http://dx.doi.org/10.1111/echo.15201DOI Listing
September 2021

Usefulness of velocity ratio in patients with moderate aortic stenosis and reduced left ventricular ejection fraction.

Scand Cardiovasc J 2021 Oct 22;55(5):270-278. Epub 2021 Jul 22.

Department of Cardiology, New Tokyo Hospital, Chiba, Japan.

. Moderate aortic stenosis (AS) increases left ventricular afterload and results in unfavorable outcomes in patients with reduced left ventricular ejection fraction (LVEF). Velocity ratio (VR) may be appropriate for the evaluation of aortic valve (AV) hemodynamics because of the low dependence on flow. Therefore, this study investigated the usefulness of VR on the clinical outcomes of such patients. . Clinical data of patients with moderate AS (AV area, 0.60-0.85 cm/m; peak AV velocity, 2.0-4.0 m/s) and reduced LVEF (LVEF 20-50%) were analyzed during 2010-2018. VR was calculated as peak left ventricular outflow tract velocity/peak AV velocity. The primary endpoint included all-cause death, heart failure hospitalization, and AV replacement. . In total, 104 patients (mean age, 75.9 ± 7.0 years; 62.5% men) were included. LVEF was 39.5% ± 7.8%. The AV area was 0.72 ± 0.08 cm/m, peak AV velocity was 2.59 ± 0.40 m/s, and VR was 0.30 ± 0.07. The follow-up period was 1.7 (0.5-3.5) years. Kaplan-Meier estimates for the endpoint were 59.9% at 3 years. Multivariable analysis revealed that VR (hazard ratio, 0.947; 95% confidence interval, 0.905-0.990;  = .018) was significantly related to this endpoint. Patients with a VR <0.25 had significantly higher incidence rates of the endpoint than those with a VR ≥0.25 (85.6% versus 47.8% at 3 years;  < .001). . Patients with moderate AS and reduced LVEF have unfavorable clinical outcomes, particularly those with low VR.
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http://dx.doi.org/10.1080/14017431.2021.1955964DOI Listing
October 2021

Coronary sinus atrial septal defects in adults over the past 20 years at new Tokyo hospital: case series.

J Cardiothorac Surg 2021 May 29;16(1):150. Epub 2021 May 29.

New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan.

Background: An isolated coronary sinus (CS) atrial septal defect (ASD) is defined as a CS unroofed in the terminal portion without a persistent left superior vena cava or other anomalies. This defect is rare and part of the wide spectrum of unroofed CS syndrome (URCS). Recently, several reports have described this finding. The database of New Tokyo Hospital was searched to determine the incidence of this defect. Additionally, to raise awareness of this condition, the findings from five patients with CS ASD who underwent surgical repair at New Tokyo Hospital are discussed.

Case Presentation: The patients were three women and two men with an age range of 63-77 years. All patients underwent transthoracic echocardiography and computed tomography, and one underwent magnetic resonance imaging. In two patients, the defect was found unexpectedly intraoperatively; left-to-right shunting was apparent in the other three patients preoperatively. The pulmonary-to-systemic blood flow ratio ranged from 1.42 to 3.1 following cardiac catheterization, and oxygen saturation step-up was seen on the right side of the heart. Valvular regurgitation was seen in 4/5 patients with different combinations and degrees of mitral, tricuspid, and aortic valve involvement. Right atrial and ventricular dilation were seen in 4/5 patients; three patients had left atrial dilation. Three patients experienced atrial fibrillation, and one of these also experienced paroxysmal ventricular contractions. All patients underwent surgical repair, and some underwent multiple procedures. One patient who had previously undergone kidney transplantation died approximately 1 year postoperatively; the remaining four patients are currently experiencing good activities of daily living without symptoms.

Conclusions: CS ASD (Kirklin and Barratt-Boyes type IV URCS) comprised 1.3% of adult congenital heart surgeries and 0.07% of adult open-heart surgeries at New Tokyo Hospital from 1999 to 2019. At New Tokyo Hospital, cardiac surgery is performed mainly for patients with acquired cardiac disease, and CS ASD is rare. Early diagnosis is important, as well as early surgical repair in symptomatic patients, especially those with blood access shunts, which may overload the heart. The case of a poor prognosis in this series is noteworthy, as similar cases have not been reported previously.
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http://dx.doi.org/10.1186/s13019-021-01522-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164258PMC
May 2021

The Impact of Aortic Valvular Calcium on Transcatheter Heart Valve Distortion.

J Interv Cardiol 2021 5;2021:8829906. Epub 2021 Jan 5.

Interventional Cardiology Unit, New Tokyo Hospital, Chiba, Japan.

Objectives: To investigate the relationship between the eccentric calcification of aortic valve and transcatheter heart valve (THV) distortion and the impact of THV distortion on echo parameters and clinical outcomes.

Background: The effects of eccentric calcification of the aortic valve on the THV distortion and the relationship between THV distortion and clinical impact were not fully understood.

Methods: Patients with symptomatic severe aortic stenosis who were undergoing THV implantation were enrolled. Patients underwent preprocedural, postprocedural multislice computed tomography (MSCT), and follow-up transthoracic echocardiogram (TTE). (ΔCS) is defined as the difference between the maximum and minimal calcium scores of the three cusps, while (VDS) is defined as the difference between the longest and shortest stent frame, as obtained using MSCT. Patients were divided into two groups according to ΔCS: "noneccentric calcification group" and "eccentric calcification group."

Results: A total of 118 patients were enrolled (59 patients in noneccentric and 59 in eccentric calcification groups). VDS was significantly lower in the noneccentric calcification group than in the eccentric calcification group (1.31 ± 0.82 mm vs. 1.73 ± 0.76 mm, =0.004). VDS was not associated with the degree of paravalvular leak (PVL) and aortic valvular mean pressure gradient (AVPG) at 30-day and 1-year follow-up TTE and the cumulative rates of all-cause death and rehospitalization at 2-year clinical follow-up.

Conclusions: Eccentric valvular calcification was associated with longitudinal THV distortion. However, THV distortion was not associated with PVL, AVPG, and adverse clinical events during midterm follow-up.
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http://dx.doi.org/10.1155/2021/8829906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803404PMC
June 2021

Potential Impact of Right Atrial Pressure on Acute Predominant Right-to-Left Shunt Across an Iatrogenic Atrial Septal Defect After MitraClip Procedure.

J Cardiothorac Vasc Anesth 2021 May 15;35(5):1461-1465. Epub 2020 May 15.

Department of Cardiology, New Tokyo Hospital, Chiba, Japan.

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http://dx.doi.org/10.1053/j.jvca.2020.04.028DOI Listing
May 2021

Successful use of the loop snare technique for crossing a degenerated surgical valve with the Evolut-R system.

Catheter Cardiovasc Interv 2019 Jun 9;93(7):E400-E402. Epub 2019 Feb 9.

Department of Cardiology, New Tokyo Hospital, Chiba, Japan.

We first report the case highlighting a loop snare wire technique may be a useful percutaneous treatment option when faced with difficulty crossing the Evolut-R system into a surgical valve due to interference between the two prostheses, especially in cases with a very horizontal aorta.
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http://dx.doi.org/10.1002/ccd.28118DOI Listing
June 2019

Periprocedural and Long-Term Outcomes of Stent Implantation for De Novo Subclavian Artery Disease.

Vasc Endovascular Surg 2019 May 29;53(4):284-291. Epub 2019 Jan 29.

1 Department of Cardiology, New Tokyo Hospital, Chiba, Japan.

Introduction: The purpose of the current study was to investigate the periprocedural and long-term outcomes of stent implantation for de novo subclavian artery (SCA) disease.

Material And Methods: We retrospectively investigated consecutive patients with de novo SCA lesions undergoing elective endovascular therapy procedures at our center between April 2004 and September 2015. All patients were included in the analyses of periprocedural outcomes, including procedural and clinical success. Subsequently, patients who completed the clinical follow-up and were assessed with brachial systolic pressure differences between the diseased and the contralateral arms, or angiographic stenosis, after stent implantation with procedural success were included in the analyses of long-term outcomes, including primary patency.

Results: There were 62 patients (median 71.0 years, interquartile range 65.3-76.0 years; 45 men) with 62 de novo SCA lesions included in the analyses of periprocedural outcomes. There were 46 stenoses (74.2%) and 16 occlusions (25.8%). Our results indicated high procedural success rates for overall (95.2%), stenotic (97.8%), and occlusive (87.5%) lesions. Similarly, high clinical success rates were observed for overall (91.9%), stenotic (93.5%), and occlusive (87.5%) lesions. The median follow-up time was 6.0 years (interquartile range, 2.6-8.3 years). There were 48 patients with 48 de novo SCA lesions included in the analyses of long-term outcomes. Primary patency estimates were 97.7% (1 year), 97.7% (3 years), 93.1% (5 years), and 87.6% (7 years). Also, we observed a high estimate for freedom from reintervention for the target vessel (93.8%).

Conclusion: Stent implantation for de novo SCA disease can be performed successfully and safely with favorable periprocedural and long-term outcomes.
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http://dx.doi.org/10.1177/1538574418824444DOI Listing
May 2019

Clinical Outcomes of Drug-Eluting Balloon for In-Stent Restenosis Based on the Number of Metallic Layers.

Circ Cardiovasc Interv 2018 08;11(8):e005935

Interventional Cardiology Unit, New Tokyo Hospital, Chiba, Japan.

Background: This study assesses clinical outcomes after drug-eluting balloon treatment for recurrent in-stent restenosis lesions based on the number of metallic layers.

Methods And Results: We enrolled 304 consecutive patients (333 lesions) treated with percutaneous coronary intervention using drug-eluting balloon for in-stent restenosis lesions between March 2014 and June 2015. Per the number of stent layers previously implanted to the lesion, the patients were categorized into 3 groups, 1 stent layer (1L), 166 patients; 2 stent layers (2L), 87 patients; and ≥3 stent layers (≥3L), 51 patients. The end points were major adverse cardiovascular events (MACE), including cardiac death, target lesion revascularization, myocardial infarction, and definite or probable stent thrombosis. No significant differences were observed in patients' baseline characteristics among the groups. The 1-year MACE and target lesion revascularization rates were significantly higher in the ≥3L group than those in the 1L and 2L groups (MACE: 1L, 16.9%; 2L, 16.1%; and ≥3L, 43.1%, P<0.01; target lesion revascularization: 1L, 14.5%; 2L, 14.9%; and ≥3L, 41.2%, P<0.01). The multivariable Cox regression analysis revealed that the number of metallic layers (≥3L compared with 1L; hazard ratio, 3.17; [95% CI, 1.75-5.76]; P<0.01 and hemodialysis [hazard ratio, 2.21; (95% CI, 1.12-4.36); P=0.02]) were independent predictors for MACE. No significant differences were observed in the occurrence of cardiac death among the groups ( P=0.34).

Conclusions: Seemingly, drug-eluting balloon is less effective for ≥3L in-stent restenosis lesions. Hemodialysis and in-stent restenosis with the number of metallic layers are independent predictors for MACE.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.117.005935DOI Listing
August 2018

Six-Month Follow-up Images of 3D Transesophageal Echocardiography and Computed Tomography After SAPIEN3 Implantation in the Descending Aorta.

Can J Cardiol 2018 09 12;34(9):1233.e17-1233.e19. Epub 2018 Jul 12.

Department of Cardiology, New Tokyo Hospital, Chiba, Japan.

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http://dx.doi.org/10.1016/j.cjca.2018.06.020DOI Listing
September 2018

Mechanical Thrombectomy in Anterior Circulation Occlusion Could Be More Effective than Medical Management Even in Low DWI-ASPECTS Patients.

Neurol Med Chir (Tokyo) 2018 Apr 23;58(4):156-163. Epub 2018 Feb 23.

Department of Neurosurgery, Kochi Health Sciences Center.

The purpose of this study was to investigate whether patients with low preoperative Diffusion-weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) could benefit from mechanical thrombectomy for acute anterior circulation occlusion. This was a retrospective, non-blinded, cohort study. From September 2012 to August 2016, 83 consecutive patients of acute anterior circulation occlusion were treated with thrombectomy using second-generation devices or medical management. The DWI-ASPECTS was scored after the first MRI. Patient characteristics and clinical outcomes were compared between the treatment groups. Significant dependence was defined as a modified Rankin scale score ≥3 at 90 days. As a result, 33 patients underwent mechanical thrombectomy and 50 received medical management. In the mechanical thrombectomy group, the variable of lower DWI-ASPECTS (5, 4-6 vs. 8, 7-8, P < 0.001), especially ≤6, was significantly associated with poor prognosis. However, compared with patients of DWI-ASPECTS ≤ 6 who received medical management, there were significantly fewer patients with poor outcomes in thrombectomy (dependent in 11 of 15 vs. 23 of 23, respectively; P = 0.019). Although patients with lower pretreatment DWI-ASPECTS could benefit less from thrombectomy, their outcomes were still better than medical management. Therefore, mechanical thrombectomy could be considered in some patients with low pretreatment DWI-ASPECTS.
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http://dx.doi.org/10.2176/nmc.oa.2017-0203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5929913PMC
April 2018

A "double crossover technique" in an obese patient undergoing transfemoral transcatheter aortic valve implantation: How to accomplish hemostasis percutaneously?

Cardiovasc Revasc Med 2017 Sep 2;18(6):440-444. Epub 2017 Apr 2.

Department of Cardiology, New Tokyo Hospital, Chiba, Japan. Electronic address:

Percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) is generally an acceptable procedure but may be associated with vascular complications at femoral access sites, particularly in obese patients. This report aimed to describe a case of successful performance of our "double crossover technique" in an obese patient undergoing TF-TAVI with a percutaneous transfemoral intra-aortic balloon pump (TF-IABP). A 75-year-old man presented with heart failure due to a left ventricular ejection fraction of 35% and low-flow, low-gradient severe aortic stenosis. The logistic EuroSCORE and STS-PROM score were 31.38% and 7.311%, respectively. Right TF-TAVI using a 14-Fr expandable sheath and a left TF-IABP using an 8-Fr sheath were scheduled. The patient was obese, with a body mass index of 31.7kg/m, and we expected access site-related vascular complications to occur. Subsequently, we performed a femoral and brachial crossover technique, called the "double crossover technique," at the completion of the TAVI procedure: first, for the right common femoral artery (CFA) through the sheath in the left CFA and second, for the left CFA through the sheath in the right brachial artery. In the crossover technique, an 8.0-mm-diameter over-the-wire balloon was advanced to an external iliac artery and was subsequently inflated when the sheath was removed. For the right CFA, a double preclose technique was used with the crossover technique. There was no evidence of access site-related vascular complications following TAVI. The double crossover technique was effective at achieving hemostasis and avoiding access site-related vascular complications in an obese patient undergoing TF-TAVI with a TF-IABP.
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http://dx.doi.org/10.1016/j.carrev.2017.03.030DOI Listing
September 2017

Long-term follow-up of first generation versus new-generation drug-eluting stents in three-vessel coronary artery disease.

Cardiovasc Revasc Med 2017 Oct - Nov;18(7):492-496. Epub 2017 Apr 21.

Department of Cardiology, New Tokyo Hospital, Chiba, Japan.

Backgrounds: Few reports have primarily focused on long-term clinical outcomes in three-vessel disease when patients were treated with either first- or new-generation drug-eluting stents (DES). The purpose of this study was to investigate different clinical outcomes after percutaneous coronary intervention (PCI) for three-vessel disease with first- or new-generation DES.

Methods: Between January 2007 and December 2013, a total of 200 patients who received complete revascularization of three-vessel disease with either first-generation DES (n=85) or new-generation DES (n=115) were analyzed in this retrospective study. Primary endpoint was the incidence of major adverse cardiac events (MACE) defined as composite endpoints of cardiac death, myocardial infarction, and target lesion revascularization at 3years.

Results: The event-free survival rate of MACE at 3years in the new-generation DES group was significantly higher than that in the first-generation group (62% vs. 77%, log rank p=0.02). The Cox regression multivariate analysis revealed that renal dysfunction [hazard ratio (HR): 2.14, 95% confidence interval (CI): 1.09-4.22; p=0.03], use of statins (HR: 0.54, 95% CI: 0.32-0.90; p=0.02) and first-generation DES (HR: 2.07, 95% CI: 1.22-3.49; p=0.01) were independent predictors of MACE.

Conclusions: These findings indicated that in patients with three-vessel disease, PCI with new-generation DES is associated with a significantly increased event-free survival rate of MACE at 3years as compared to first-generation DES.
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http://dx.doi.org/10.1016/j.carrev.2017.04.006DOI Listing
June 2018

Can we perform rotational atherectomy in patients with severe aortic stenosis? Substudy from the OCEAN TAVI Registry.

Cardiovasc Revasc Med 2017 Jul - Aug;18(5):356-360. Epub 2017 Feb 28.

Keio University School of Medicine, Tokyo, Japan.

Purpose: The aim of this study was to report the safety of coronary rotational atherectomy (RA) in patients with severe aortic stenosis (AS). RA in the clinical setting seems challenging because coronary slow flow leads to hemodynamic instability.

Methods: Between October 2013 and May 2016, 1401 patients in the Optimized transCathEter vAlvular iNtervention (OCEAN) registry in Japan underwent transcatheter aortic valve implantation (TAVI). The primary study endpoint was procedural success, defined as residual stenosis <20% with final Thrombolysis in Myocardial Infarction flow 3.

Results: Twenty-five patients who underwent RA for heavily calcified lesions were included in the study. Low left ventricular ejection fraction (<35%) was present in 3 (12%) patients. The left main stem was involved in 7 (28%) patients. All patients were treated under intravascular image guidance. Intra-aortic balloon pumping was used in 4 (16%) patients. Planned balloon aortic valvuloplasty (BAV) was performed during the same session in 4 (16%) patients. Transvenous catecholamine was used in 10 (40%) patients. The majority of patients underwent drug-eluting stent implantation following RA (n=23, 92%). Procedural success was achieved in all patients. Subsequent device success was achieved in 24 (96%) patients, with no 30-day mortality following TAVI.

Conclusions: RA in patients with severe AS seems extremely challenging; however, this procedure appears to be safe if mechanical and drug supports are appropriately utilized and the procedure is performed under intravascular image guidance.
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http://dx.doi.org/10.1016/j.carrev.2017.02.018DOI Listing
May 2018

Delayed expansion of an intracranial cyst induced by ventriculoperitoneal shunt in a patient with Chiari malformation type 2.

Brain Dev 2017 Jun 11;39(6):529-531. Epub 2017 Feb 11.

Department of Neurosurgery, Kochi Health Sciences Center, Kochi, Japan. Electronic address:

A male neonate was referred to our hospital for the treatment of myelomeningocele and hydrocephalus related to Chiari malformation type 2. After the placement of ventriculoperitoneal (VP) shunt for hydrocephalus, an intracranial cyst, which was asymptomatic at first, expanded and caused clinical symptoms due to increased intracranial pressure. The expansion of the cyst was confirmed dominantly in the right lateral ventricle where the VP shunt was inserted. Intraoperative findings through a neuroendoscope suggested that the expanded cyst was an isolated lesion. The pressure reduction in the lateral ventricle through the shunt tube, not the malfunction of the VP shunt, might have attributed to increased intracranial pressure with the expanded cyst. The authors present this rare case, speculating the cause of the expansion of the cyst.
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http://dx.doi.org/10.1016/j.braindev.2017.01.009DOI Listing
June 2017

Early predictors for massive transfusion in older adult severe trauma patients.

Injury 2017 May 29;48(5):1006-1012. Epub 2016 Dec 29.

Department of Orthopaedic Surgery, Kochi Health Sciences Center, Kochi, Japan.

Background: Many scoring systems for the early prediction of the need for massive transfusion (MT) have been reported; in most of these, vital signs are regarded as important. However, the validity of these scoring systems in older patients remains unclear because older trauma patients often present with normal vital signs. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients.

Methods: We prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16years) admitted from January 2007 to March 2015. Trauma Associated Severe Hemorrhage (TASH), Assessment of Blood Consumption (ABC), and Prince of Wales Hospital (PWH) scores were compared between a younger and an older group. Furthermore, the predictors associated with MT in older severe trauma patients were assessed using multivariable logistic regression analyses.

Results: The area under the curve (AUC) was significantly smaller for older group than for younger group for all three scoring systems (p<0.05). The most important risk factors to predict the need for MT were related to anatomical factors including FAST results (odds ratio (OR): 5.58, 95% confidence interval (CI): 2.10-14.99), unstable pelvic fracture (OR: 21.56, 95% CI: 6.05-90.78), and long bone open fracture of the lower limbs (OR: 12.21, 95% CI: 4.04-39.09), along with pre-injury anticoagulant agent use (OR: 5.22, 95% CI: 1.30-19.61), antiplatelet agent use (OR: 3.81, 95% CI: 1.57-9.04), lactate levels (OR: 1.20, 95% CI: 1.04-1.39) and shock index (OR: 2.67, 95% CI: 1.05-6.84). Traditional vital signs were not early risk factors.

Conclusion: We suggest that MT in older trauma patients should be considered on the basis of anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.
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http://dx.doi.org/10.1016/j.injury.2016.12.028DOI Listing
May 2017

Bleeding sites in elderly trauma patients who required massive transfusion: a comparison with younger patients.

Am J Emerg Med 2016 Feb 3;34(2):123-7. Epub 2015 Oct 3.

Department of Orthopaedic Surgery, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555.

Introduction: Among elderly patients with severe trauma, the sites of massive hemorrhage and their clinical characteristics are not well understood. Therefore, we investigated the sites of massive hemorrhage in patients with severe trauma, and compared the results for younger and elderly patients.

Methods: A cohort of severe trauma patients (Injury Severity Score ≥16) admitted from March 2007 to December 2014 was reviewed retrospectively. The inclusion criterion was massive bleeding, which was defined as bleeding that required the transfusion of ≥10 red cell concentrate units within 24 hours of admission, or as cases of early death that occurred despite continuous blood transfusion and before the patient could receive ≥10 red cell concentrate units within the first 24 hours after their admission.

Results: Eighty-four patients met our inclusion criterion. The younger group (<65 years old) included 40 patients (48%), whereas the older group (≥65 years old) included 44 patients (52%). The percentage of nondiagnosable cases at the primary survey (massive bleeding due to multisite damage caused by a bone fracture or contusion, retroperitoneal hematoma without a pelvic ring fracture and with stable pelvic ring fracture) was 14% in the younger group and 40% in the older group (odds ratio, 3.92; 95% confidence interval, 1.37-11.27, P = .017).

Conclusions: Even if no abnormalities are observed at the primary survey of elderly patients with severe trauma, physicians should consider the possibility of massive bleeding.
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http://dx.doi.org/10.1016/j.ajem.2015.09.047DOI Listing
February 2016

Effect of pre-injury anticoagulant and antiplatelet agents on blood loss in elderly patients with severe trauma.

Acute Med Surg 2016 04 27;3(2):114-119. Epub 2015 Aug 27.

Emergency and Critical Care Center Kochi Health Sciences Center Kochi Japan.

Aim: It has been widely reported that pre-injury use of anticoagulant and antiplatelet agents can affect traumatic brain injury and the associated risk of mortality, however, the effect of these agents on non-head injury site-related blood loss remains unclear. Therefore, we investigated the effects of pre-injury anticoagulant and antiplatelet agents on the transfusion amount and the need for massive transfusion in elderly patients with severe trauma.

Methods: We retrospectively reviewed a cohort of elderly patients with severe trauma (age, ≥65 years; Injury Severity Score, ≥16) between September 2006 and March 2014. The selected patients were subsequently divided into patients who were: only taking warfarin, aspirin, or clopidogrel; taking various combinations of these agents; and a control group who were not taking any of these agents.

Results: During the study period, 67 patients (20%) were taking anticoagulant and antiplatelet agents and 272 patients were included in the control group. Among these patients, 10 were receiving only warfarin, 28 were receiving only aspirin, 14 were receiving only clopidogrel, and 13 were receiving various combinations of these medications. The amount of red cell concentrate and need for massive transfusions were only significantly increased in the warfarin group ( < 0.05). Furthermore, the warfarin group had a significantly higher risk of needing a massive transfusion with multivariate logistic regression analysis (odds ratio, 5.03; 95% confidence interval, 1.25-20.20;  < 0.05).

Conclusion: Patients who were receiving only warfarin before their injury had an increased risk of bleeding due to non-head injuries.
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http://dx.doi.org/10.1002/ams2.152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5667378PMC
April 2016

Admission fibrinogen levels in severe trauma patients: A comparison of elderly and younger patients.

Injury 2015 Sep 24;46(9):1779-83. Epub 2015 Apr 24.

Department of Orthopaedic Surgery, Kochi Health Sciences Center, Japan.

Introduction: Acute coagulopathy of trauma has been much discussed recently. However, the changes in coagulation markers after trauma in the elderly are unknown. Furthermore, the baseline fibrinogen level is high in elderly patients, and the question remains as to whether fibrinogen levels also decrease early and the degree of decrease in elderly trauma patients. The purpose of this study was to compare coagulation markers including the fibrinogen level on admission in younger and elderly severe trauma patients.

Methods: A cohort of severe trauma patients (Injury Severity Score (ISS) ≥16), admitted from January 2011 to June 2014, with coagulation markers including the fibrinogen level on admission available, was reviewed retrospectively. The patients were divided into a younger (16-64 years old) and an older (≥65 years old) group based upon their age at presentation. Activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen, and D-dimer were compared between the younger and older groups.

Results: There were 251 patients who met the inclusion criteria for this analysis. The younger group included 117 patients and the older group included 134 patients. The median aPTT (26.3 vs 27.5s, P=0.001) and median D-dimer levels (18.8 vs 40.2 μg/dL, P=0.006) were significantly higher in the older group. However, the fibrinogen level (205 vs 248 mg/dL, P<0.001) was significantly higher in the older group. The regression lines of fibrinogen and age in non-massive transfusion and massive transfusion cases are given by Y=1.03 X+185 (r=0.24, r(2)=0.06, P<0.001) and Y=0.86 X+134 (r=0.25, r(2)=0.06, P=0.09) respectively, and the fibrinogen levels tended to increase with older age in severe trauma patients.

Conclusions: The fibrinogen level did not show a low value as it can in younger patients in elderly patients. Therefore, the fibrinogen level is difficult to use as an early indicator of acute blood loss with haemorrhage in elderly severe trauma patients, as it can be used in younger patients. Thus, it is necessary to keep in mind that the fibrinogen level increases by approximately 1mg/dL when the age increases by 1 year and to carefully observe the fibrinogen level even if the admission level is not low.
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http://dx.doi.org/10.1016/j.injury.2015.04.007DOI Listing
September 2015

Carotid Endarterectomy for Pseudo-occlusion of the Cervical Internal Carotid Artery.

Acta Neurochir Suppl 2014;119:91-6

Department of Neurosurgery, Japanese Red Cross Fukuoka Hospital, 3-1-1 Ookusu, Minami-ku, Fukuoka city, Fukuoka, 815-8555, Japan,

Object: This study described clinicopathological characteristics of pseudo-occlusion (PO) of the internal carotid artery (ICA) with regards to the pathological mechanism and the benefit of carotid endarterectomy (CEA).

Methods: We retrospectively reviewed 17 PO patients who underwent CEA. Clinical presentation, angiographic findings, surgical outcomes and plaque components obtained from CEA were investigated.

Results: PO plaques had more fibrous and two different pathological features, including total occlusion with recanalization and severe stenosis. Plaques of the total occlusion with recanalization (8 patients) were composed of thrombotic total occlusion and lumen recanalization by large neovascular channels, whereas those with severe stenosis (9 patients) were fibrous or fibroatheromatous plaque with severe stenosis of the original lumen. Of all the patients who underwent a carotid angiogram 2 weeks after surgery, 16 were successfully treated, but one showed complete occlusion of the ICA. At the follow-up period, two patients showed restenosis of the ICA. Three patients with complete occlusion or restenosis had histologically fibrous sclerotic plaques.

Conclusion: Patients with PO had more fibrous plaques and two different histological features, including total occlusion with recanalization or severe stenosis. The plaque histology may be related to the pathogenesis and the surgical outcome.
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http://dx.doi.org/10.1007/978-3-319-02411-0_16DOI Listing
January 2014

Quantitative assessment of gliomas by proton magnetic resonance spectroscopy.

Anticancer Res 2007 Nov-Dec;27(6A):3757-63

Department of Neurosurgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.

Background: Advanced magnetic resonance (MR) techniques provide physiological and metabolic information that complements the anatomical information available from conventional MR imaging. The purpose of this study was to evaluate the clinical usefulness of proton MR spectroscopy (1H-MRS) in preoperative quantitative assessment of intracranial gliomas.

Patients And Methods: Eight patients with histologically verified gliomas, comprising 2 cases with glioblastoma multiforme (GBM, grade 4), 5 cases with anaplastic oligodendroglioma (AO, grade 3; high-grade glioma), and 1 case with fibrillary astrocytoma (FA, grade 2; low-grade glioma) were evaluated using the 1H-MRS protocol following conventional MR imaging, diffusion-weighted imaging (DWI), and perfusion-weighted imaging (PWI) preoperatively.

Results: High-grade gliomas tended to demonstrate signal hyperintensity by DWI and higher relative cerebral blood volume (rCBV) by PWI. Increased ratios of choline (Cho) to N-acetylaspartate (NAA) (Cho/NAA) and Cho to creatine (Cr) (Cho/Cr) correlated highly with tumor malignancy. The presence of lactate and lipid was predominately detected in patients with high-grade glioma.

Conclusion: The combination of multiple MR parameters, based on DWI, PWI and 1H-MRS, appears valuable for preoperatively predicting the degree of malignancy in glioma.
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December 2007

Anti-tumor activity of de novo designed small globular protein (SGP) in vivo.

Anticancer Res 2006 Nov-Dec;26(6A):4043-6

Department of Neurosurgery, School of Medicine, Fukuoka University, 45-1, 7-chome Nanakuma Jonan-ku, Fukuoka 814-0180, Japan.

Background: The design and synthesis of a small globular protein (SGP) based on the colicin family of bacteriocins has previously been reported. It has subsequently been shown that this artificial protein possessed cell membrane-disrupting properties. Here, the anti-tumor effects of SGP in subcutaneous nude mice tumor models of human glioma were examined.

Materials And Methods: Human glioblastoma cells (U-87MG) were transplanted subcutaneously into the backs of nude mice. When tumor volume was between 100 mm(3) and 350 mm(3), tumors were locally injected with SGP three times a week. The four SGP injection groups were 0.5 mM/50 microl, 0.5 mM/100 microl, 1.0 mM/50 microl and 1.0 mM/100 microl (concentration/injection volume). The control group was injected with physiological saline; 100 microl three times a week.

Results: Tumor volume exhibited a statistically significant decrease (p=0.001) and survival was significantly longer in the SGP-injected groups (p=0.0001). No clear difference in survival time was observed between the 0.5 mM SGP and 1.0 mM SGP groups (p=0.0654). However, the reduction in tumor volume was significantly affected by SGP concentration (p=0.021).

Conclusion: SGP has an anti-tumor effect in human glioma animal models. The present results also suggest that applied treatment based on local injection of SGP will be effective against deep brain-seated malignant glioma.
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January 2007

Mechanisms of small globular protein-induced plasma membrane permeability and cytotoxicity in U87-MG human malignant glioblastoma cells.

Anticancer Res 2006 Nov-Dec;26(6A):4033-41

Department of Neurosurgery, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.

Background: Small globular protein (SGP) is an artificially designed protein that forms small pores on lipid bilayer membranes. The anti-tumor effect of SGP has been reported in several papers. However, the exact mechanism underlying SGP-induced cell death remains to be determined.

Materials And Methods: The mechanisms of SGP-mediated cytotoxicity were examined using cultured malignant glioblastoma cells (U87-MG). Morphological changes were observed under a light microscope. Ultrastructural changes were examined by electron microscopy. Changes in membrane permeability were evaluated by measuring the extracellular release of lactate dehydrogenase (LDH) and intracellular calcium concentration ([Ca2+]i). A new cell viability assay was also conducted using DAPI/calcein fluorescent-double staining methods.

Results: SGP cytotoxic effects were strongly influenced by fetal bovine serum (FBS) concentration in culture media. After 30 min of incubation, cytotoxic effects were noted at SGP concentrations greater than 1.5 microM. [Ca2+]i increased immediately after SGP addition. Extracellular efflux of LDH increased linearly with SGP doses (r(2) =0.936), and occurred even at concentrations less than 1.5 microM. Non-viable and viable cells were simultaneously detected by fluorescent staining with DAPI and calcein-AM, respectively. After 30 min of incubation with SGP, DAPI-positive nuclei were evident at concentrations higher than 1.5 microM. Cultures were then maintained in 10% FBS-containing media for 24 h before addition of calcein-AM. Calcein-positive cells were found at SGP concentrations lower than 1.5 5M. Cells positive for both DAPI and calcein appeared at a concentration of 1.5 microM.

Conclusion: Our results indicate that SGP induces rapid but transient cytotoxicity, which may be beneficial in local therapy of malignant brain tumors.
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January 2007
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