Abstract Objective The number of older patients with acute aortic dissection type A (AAD A) is increasing as the population ages. We evaluated clinical outcomes for octogenarians with AAD (A) treated ...surgically at our hospital. Whenever possible, we limited the replacement site of the ascending aorta to the supracoronary and hemiarch. Methods Of 436 patients with AAD (A) seen in our hospital emergency room between April 2001 and August 2015, 90 were octogenarians. Surgery was performed using a simple cardiopulmonary bypass established through the right femoral artery and venous cannulation, and distal anastomosis was performed under deep hypothermic circulatory arrest at 20°C. Results Of the 90 octogenarians with AAD (A), 11 required cardiopulmonary resuscitation, 9 of whom died. Four patients with stable hemodynamics refused surgery. Thus, 77 were treated surgically. Of these 77 patients, isolated replacement of the ascending aorta or hemiarch was performed in 73 (94.8%), and total arch replacement in 4 (5.2%). Five patients (6.5%) died within 30 days, and 5 (6.5%) died in the hospital more than 30 days after surgery. Seven (9.1%) had a new stroke, 5 (6.5%) had pneumonia, and 4 (5.2%) had mediastinitis. Forty-four (57.1%) patients were discharged to their homes and 23 (30%) to rehabilitation hospitals. Three patients later required endovascular stent graft repair, which was successful in each case. The overall postoperative survival was 82%, 70%, and 62% at 1, 3, and 5 years, respectively. Conclusions Our results suggest that our limited replacement protocol for emergency AAD (A) surgery has early and midterm survival benefits for octogenarians.
Background:In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as ...with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean ±SD age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean ±SD 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval CI 1.0–3.7; P=0.049) and 2.4 (95% CI 1.2–4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1–0.8; P=0.024).Conclusions:NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.
Background:There are few reports of the determinants of “functional” mitral stenosis in terms of a residual mitral valve (MV) pressure gradient >5 mmHg following restrictive mitral annuloplasty (RMA) ...or the effect on long-term outcome in patients with functional mitral regurgitation (MR).Methods and Results:Serial cardiac catheterization and echocardiographic studies were performed in 55 patients with functional MR who underwent RMA using a 24/26-mm semi-rigid complete ring. The mean postoperative (1 month) catheter-measured MV gradient was 3.4±1.6 mmHg, which was independently associated with corresponding cardiac output standardized partial regression coefficient (SPRC)=0.59 and indexed effective orifice area (SPRC=−0.25). Body surface area (BSA) had the greatest contribution to MV gradient (SPRC=0.38), followed by use of a 24-mm ring (SPRC=0.33) and hemodialysis (SPRC=0.26). Receiver-operating characteristic curve analysis demonstrated an optimal BSA cutoff value of 1.86 m2to predict post-MV stenosis (21% for <1.86 m2vs. 86% for ≥1.86 m2, P=0.002). During follow-up (75±32 months), freedom from adverse events did not differ between patients with (n=16) and without (n=39) an MV gradient ≥5 mmHg (log-rank P=0.24).Conclusions:Post-RMA MV gradient was determined not only by the degree of annular reduction but also by patients’ hemodynamic factors (e.g., cardiac output). Implantation of a 24/26-mm annuloplasty ring for patients with BSA ≥1.86 m2indicated a high likelihood of post-MV stenosis. However, mild MV stenosis did not adversely affect late outcome after RMA.
Geometric changes caused by volume reduction early after aortic valve replacement (AVR) for aortic regurgitation (AR) may not be uniform, resulting in varying regional end-systolic wall stress (ESS). ...This study compared changes in regional ESS between AR and aortic stenosis (AS) patients in the early phase following AVR. Computer-tomographic left ventricular (LV) angiography was performed for 10 patients with AR and 13 with AS before and three months after AVR. Regional ESS at the base, middle, and apex levels, each subdivided into four segments, was calculated based on the Janz equation: ESS = end-systolic LV pressure × local cross-sectional area of LV cavity/that of LV wall. Following AVR, median LV end-diastolic volume index fell from 106 to 69 ml/m
2
(
P
= 0.001) in AR and 60 to 46 ml/m
2
(
P
= 0.01) in AS patients. Global ESS also declined in both (AR, 186 to 124 kdyne/cm
2
,
P
= 0.02; AS, 187 to 108 kdyne/cm
2
,
P
< 0.001, respectively). Regional ESS was reduced in all segments in AS patients, accompanied by left ventricular ejection fraction (LVEF) improvement (71–80%,
P
= 0.02). In contrast, regional ESS in AR patients was heterogeneously reduced, as regional ESS fell significantly in the antero-septal wall but was unchanged in the infero-lateral wall, and LVEF remained unchanged (65 to 62%,
P
= 0.42). In the early postoperative phase after AVR, the loading condition of the regional LV wall in AR patients was characterized by a heterogeneous reduction in regional ESS in contrast to a uniform decline in AS patients.
Autologous skeletal myoblast cell transplantation by means of the injection method is subject to the loss of intercellular communication, extracellular matrix, and cell numbers. We hypothesize that ...the implantation of skeletal myoblast cell sheets might be more advantageous in repairing the impaired heart by providing uniform and stable cell delivery with less cell loss and without disrupting the cell-cell microenvironment.
Left anterior descending coronary artery–ligated Lewis rat hearts (2 weeks, total n = 173) received 1 × 10
7 autologous skeletal myoblasts by means of cell transplantation either through myoblast injection or implantation of 2 monolayer-constructed myoblast sheets (5 × 10
6 cells per sheet) or through medium injection. Myoblast sheets were constructed with temperature-responsive, polymer-grafted cell-culture dishes, which release the confluent cells from the dish surface at less than 20°C.
Echocardiographic results indicated higher improvement of cardiac performance in the myoblast sheet group than among the other groups until 8 weeks after cell transplantation. Histologic comparison revealed greater cellularity and abundant widespread neocapillaries within the noticeable uniform thickened wall in myoblast sheet group hearts only. Fibrosis was substantially reduced with skeletal myoblast sheet implantation compared with skeletal myoblast cell injection. Obviously higher numbers of hematopoietic stem cells (c-kit, stem cell antigen 1, and CD34) were observed in the myoblast sheet group infarct heart region. Reverse transcription–polymerase chain reaction results showed expression of stromal-derived factor 1, hepatocyte growth factor, and vascular endothelial growth factor as follows: myoblast sheets > myoblast injection > control.
Myoblast sheets repaired the impaired myocardium, reduced fibrosis, and prevented remodeling in association with recruitment of hematopoietic stem cells through the release of stromal-derived factor 1 and other growth factors. Our experiment indicates a therapy for patients with severe heart failure.
Objectives Pulmonary hypertension (PH) is an indicator of a poor prognosis in patients with dilated cardiomyopathy. Few studies have investigated the prognostic role of PH in patients undergoing ...restrictive mitral annuloplasty (RMA) for severe functional mitral regurgitation secondary to advanced cardiomyopathy. Methods A total of 46 patients undergoing RMA were classified into 3 groups on the basis of the Doppler-derived systolic pulmonary artery pressure (PAP) at baseline. Of the 46 patients, 19 had a systolic PAP less than 40 mm Hg (mild PH group), 17 had a systolic PAP of 40 to 60 mm Hg (moderate PH group), and 10 had a systolic PAP greater than 60 mm Hg (severe PH group). Results Postoperative cardiac catheterization showed that the RMA procedure resulted in a significant reduction of the left ventricular (LV) preload and improvements in LV systolic function in all 3 groups, along with the relief of symptoms. During the follow-up period (mean, 36 ± 19 months), cardiac death occurred in 6 patients, readmission because of heart failure in 3, and fatal arrhythmia in 1. The rate of freedom from these cardiac events at 3 years was 93% ± 7%, 88% ± 8%, and 56% ± 17% in the mild, moderate, and severe PH groups ( P < .001). Serial echocardiography showed that significant LV reverse remodeling occurred in 89%, 71%, and 25% of the mild, moderate, and severe PH groups, respectively. Multivariate Cox regression analysis identified severe PH (systolic PAP > 60 mm Hg) as a significant predictor of adverse cardiac events, as well as LV remodeling after RMA. Conclusions Noninvasive assessment of preoperative PH has a prognostic value in patients undergoing RMA for severe functional mitral regurgitation secondary to advanced cardiomyopathy.
We investigated long-term outcomes following aortic valve replacement (AVR) in asymptomatic patients with severe aortic regurgitation (AR) and normal left ventricular (LV) function. We reviewed 268 ...patients who underwent isolated AVR for chronic severe AR from 1991 to 2010 and enrolled 162 asymptomatic patients with normal LV ejection fraction (≥50%) preoperatively. They were divided into 2 groups according to LV dimension at surgery, the early stage C group (indexed LV end-systolic diameter ≤25 mm/m2 and LV end-diastolic diameter ≤65 mm, n = 61), and late stage C group (indexed LV end-systolic diameter >25 mm/m2 and/or LV end-diastolic diameter >65 mm, n = 101). Survival was compared with that of an age- and gender-matched Japanese general population using a one-sample log-rank test. Subgroup analysis was performed for patients who survived >10 years after AVR. The mean age of all patients was 59 ± 14 years and mean follow-up period was 10 ± 5 years. Survival after AVR for the early and late stage C groups was not statistically different (P = 0.57). Furthermore, survival for both groups was not statistically different from that of the general population (early stage C, P = 0.63; late stage C, P = 0.14). However, subgroup analysis showed that survival >10 years after AVR was significantly worse for the late stage C group as compared to that of the general population (P < 0.001). Long-term survival following AVR for asymptomatic AR with normal LV ejection fraction was excellent. However, survival more than 10 years after surgery might be dependent on LV dimension at surgery.
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Purpose
To define the outcomes of our original simple chordal replacement technique using ePTFE sutures for mitral regurgitation.
Methods
Between January, 2004 and March, 2014, 38 patients underwent ...mitral valve repair using our chordal replacement technique for anterior leaflet prolapse. The mitral regurgitation was caused by degenerative disease in 34 patients and infective endocarditis in 4 patients.
Results
The follow-up period was 66 ± 37 months and the 5-year survival rate was 95 ± 4%. Two patients had recurrent mitral regurgitation, caused by degenerative change not associated with the procedure. The 5-year rate of freedom from recurrent mitral regurgitation was 94 ± 4%. In the late postoperative period, 15 (42%) patients had a mean pressure gradient > 5 mmHg. Stepwise logistic regression analysis showed that the use of a full ring (odds ratio 8.9; 95% confidence interval 1.2–64;
p
= 0.031) and a 26 mm annuloplasty (odds ratio 7.5; 95% confidence interval 1.1–50;
p
= 0.037) were significant independent risk factors for a mean pressure gradient > 5 mmHg.
Conclusion
The intermediate-term outcomes of our original chordal replacement technique were not inferior to those in previous reports, although a 26 mm annuloplasty was found to be associated with a higher mitral valve gradient at rest.
Myocardial ischemia associated with acute aortic dissection is frequently a fatal complication, and the emergent management still remains a challenge. We report a patient with life-threatening ...myocardial ischemia due to acute aortic dissection managed by rescue stent grafting of the ascending aorta. Coronary blood flow improved immediately with this endovascular procedure, hemodynamic status was ameliorated dramatically, followed by uneventful open repair.
Abstract Background Restrictive mitral annuloplasty (RMA) can reverse left ventricular (LV) remodeling and reduce plasma B-type natriuretic peptide (BNP), a surrogate biomarker of heart failure. ...However, the relationship between reverse LV remodeling and plasma BNP changes after RMA is poorly defined. We explored the main hemodynamic factors contributing to change in plasma BNP after RMA in patients with functional mitral regurgitation (MR). Methods Twenty-four patients with moderate to severe functional MR secondary to LV systolic dysfunction ejection fraction (EF) <40% underwent 64-row multidetector computed tomography (MDCT) before and 1.4 months after RMA. LV end-diastolic volume index (EDVI), end-systolic volume index (ESVI), LVEF, and regional and global end-systolic wall stress (ESS) were calculated from 3-dimensional MDCT images, with blood samples for plasma BNP measurement collected the same day. Results After RMA, LV volumes and global ESS were decreased, while LVEF improved (all p < 0.01). There were significant correlations between changes in LVEDVI and LVESVI ( r = 0.90, p < 0.0001), LVESVI and global ESS ( r = 0.54, p = 0.006), and global ESS and LVEF ( r = −0.60, p = 0.002). The median value for the plasma BNP also decreased from 597 pg/ml interquartile range (IQR), 360–934 pg/ml to 207 pg/ml (IQR, 124–271 pg/ml), in association with changes in LVEDVI ( r = 0.47, p = 0.019), LVESVI ( r = 0.56, p = 0.004), LVEF ( r = −0.60, p = 0.002), and global ESS ( r = 0.74, p < 0.0001). Multivariate regression analysis showed that global ESS change was the strongest contributor to change in natural-log-transformed plasma BNP (standardized partial regression coefficient = 0.59, p = 0.004), indicating a strong association between decrease in LV afterload and reduction in plasma BNP level after RMA. Conclusions There may be a significant association between LV reverse remodeling and plasma BNP change after RMA. Furthermore, LV end-systolic myocardial stress may be the key mechanical stimulus influencing plasma BNP after surgical correction for functional MR. Whether these favorable BNP responses and reverse remodeling can predict improved survival requires further study.
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