Opioid-switching (OS) is usually performed with conversion methods based on the equianalgesic dose table. However, the conversion ratios might lead to significant differences in clinical practice. No clear guideline exists for safe, effective switching from transdermal fentanyl (TF) to oxycodone injection (OXJ). We retrospectively investigated the adequate analgesia dose of OXJ in OS from TF by comparing with the equianalgesic calculated dose based on the conversion ratio of 1.0 : 41.7 between TF and OXJ. Patients with a pain scale score of 0 were assigned to the “NRS/VRS=0” group (n=4), and the remaining patients were assigned to the “NRS/VRS>0” group (n=27). During a 4-year period, 31 of 49 patients with cancer-related pain who underwent OS from TF to OXJ were investigated. All patients in the NRS/VRS=0 group (4/4, 100%) and most in the NRS/VRS>0 group (23/27, 85%) achieved adequate analgesia. Among the 27 patients with adequate analgesia, the median effective OXJ dose was 28% (interquartile range, 21-47) of the equianalgesic calculated dose in the well-controlled group and 103% (interquartile range, 71-164) in the poor analgesia group. Strong drowsiness developed in two patients the day after OS, and the OXJ dose was decreased. Our findings suggest that in patients without pain, it might be necessary to reduce the OXJ dose to approximately 30% of the equianalgesic calculated dose for safe OS from TF. Pain intensity and drowsiness due to an opioid overdose should be carefully monitored and may require dose adjustment.

We examined the surgical procedure and long-term results in patients who underwent intraoperative re-do for the completion of mitral valve repair. Between March 1993 and July 1996, 81 patients underwent mitral valve repair for pure MR using TEE evaluation. Of these, 12 patients that were judged to have more than mild residual regurgitation (MRA≥2.0cm² or MRL≥1.0cm) underwent intraoperative re-do. All of the patients were type 2, according to Carpentier's classification. Seven patients had degenerative disease and 2 had infective endocarditis. If the cause of residual MR was localized discoaptation, 5-0 suture plication with beating heart that increased the coaptation zone and resulted in decrease in the residual MR was useful. If the cause of residual MR was leaflet prolapse or dehiscence, intraoperative re-do was performed the cardiac re-arrest. Two patients of billowing valve underwent MVR and the other needed additional resection of leaflet, artificial chorda or suture. After intraoperative re-do, every procedure resulted in a reduction of MR except for 2 patients underwent MVR during the early postoperative stage, and of those all but one remaine no-to-mild MR in the late term (mean follow-up 26.2 months). In conclusion, 5-0 suture plication was effective for intraoperative re-do procedures, and basic mitral valve repair modification was necessary in about half of the cases. Intraoperative re-do was safely performed with no mortality or morbidity and it yielded good long term results. Intraoperative TEE evaluation was considered to be important.

The left atrium and left atrial appendage have unique genetic anatomical and physiological features. Recently, advances in diagnostic imaging technology have provided much new knowledge. Clinically, the risk of developing atrial fibrillation increases with age. In order to reduce the public health burden such as cerebral infarction caused by atrial fibrillation, we need to find some predictive risk factors and preventive strategies for cerebral infarction and more effective treatments. The new concept of atrial myopathy has emerged, and animal models and human studies have revealed close interactions between atrial myopathy, atrial fibrillation, and stroke through various mechanisms. Structural and electrical remodeling such as fibrosis and deterioration of the balance of autonomic nerves and complicated interactions between these mechanisms lead to deterioration of atrial fibrillation and a continuous vicious cycle, and finally thrombosis in the left atrial appendage. Although anticoagulant therapy for patients with atrial fibrillation is strongly recommended, it is difficult for many patients to continue optimal treatment. In the nearly future, it will be important to understand the anatomy and physiology of the left atrial appendage and to understand the shape changes, size and the changes of autonomic function, and thrombus formation conditions associated with LAA remodeling during atrial fibrillation, and then we should provide early therapeutic intervention.

Background/Aims: The Heart Failure Association (HFA)-PEFF score is recognized as a simple method to diagnose heart failure (HF) with preserved ejection fraction (HFpEF). This study aimed to evaluate the relationship between HFA-PEFF scores and cardiovascular outcomes in HFpEF patients. Methods: A total of 502 consecutive HFpEF patients were prospectively observed for up to 1,500 days. Cardiovascular outcomes were compared between two groups of patients, defined by their HFA-PEFF scores: those who scored 2–4 (the intermediate-score group) and those who scored 5–6 group (the high-score group). Overall, 236 cardiovascular events were observed during the follow-up period (median, 1,159 days). Results: Kaplan-Meier analysis showed that there were significant differences in composite cardiovascular events and HF-related events between the intermediate-score group and the high-score group (p = 0.003 and p < 0.001, respectively). Multivariate Cox proportional hazards analysis showed that the HFA-PEFF scores significantly predicted future HF-related events (hazard ratio, 1.66; 95% confidence interval [CI], 1.11 to 2.50; p = 0.014); receiver operating characteristic analysis confirmed this relationship (area under the curve, 0.633; 95% CI, 0.574 to 0.692; p < 0.001). The cutoff HFA-PEFF score for the identification of HF-related events was 4.5. Decision curve analysis revealed that combining the HFA-PEFF score with conventional prognostic factors improved the prediction of HF-related events. Conclusions HFA-PEFF scores may be useful for predicting HF-related events in HFpEF patients.