Background: Despite the cosmetic benefits of the minimally invasive approach for mitral disease, the clinical benefit and risk are not fully known. We investigated the benefit and risk of minimally ...invasive mitral valve (MV) repair for type II dysfunction using propensity score-matched analysis. Methods and Results: Since 2001, 602 patients have undergone MV repair for type II dysfunction (464 with conventional median sternotomy and 138 with the minimally invasive approach). One-to-one matched analysis using the estimated propensity score based on 23 factors resulted in 93 well-matched patient pairs. There was no in-hospital death in both groups. The operation time was significantly shorter (P=0.002), blood transfusion was less frequent (P=0.04), extubation at the day of surgery was more frequently performed (P=0.017), and the length of hospital stay was significantly shorter in the minimally invasive group than in the sternotomy group (P<0.0001). On postoperative (P=0.02) and 1-year echocardiography (P=0.04), ejection fraction was lower in the minimally invasive group than in the sternotomy group. There were no significant differences in postoperative cerebral infarction, aortic dissection, deep sternal infection, or mid-term outcome between the groups. Conclusions: Standard sternotomy and the minimally invasive approach provide similar good quality of MV repair for type II dysfunction. The minimally invasive approach is more likely to contribute to fast-track perioperative treatment than the standard sternotomy approach.
Management of native aortic insufficiency (AI) during left ventricular assist device (LVAD) support is challenging. We investigated the occurrence of de novo AI during long-term LVAD support to ...identify its effect on late clinical and echocardiographic outcomes.
Left ventricular assist devices were implanted in 99 patients with dilated cardiomyopathy, of whom 47 without preoperative AI were investigated using serial echocardiography examinations for more than 1 year after the operation.
The mean duration of LVAD support was 838±327 days, and 26 patients (55%) were supported for more than 2 years. Twenty-nine patients (62%) had no AI (group A), whereas de novo AI developed in the remaining 18 (38%; group B) at 1 year after LVAD implantation (≥grade 2 in 5, grade 1 in 13). The LV end-diastolic diameter was significantly reduced after LVAD implantation in both groups, with no significant difference between them. Overall survival was better in group A (p=0.0195). Multivariate analysis revealed that preoperative mitral regurgitation of more than grade 2 (odds ratio, 7.8; 95% confidence interval, 1.2 to 48.6; p=0.028) and an aortic valve that remained closed at 1 month after implantation (odds ratio, 6.7; 95% confidence interval, 1.0 to 43.9; p=0.048) were significant independent predictors of de novo AI at 1 year after LVAD implantation.
Survival was significantly worse when de novo AI developed in patients during long-term LVAD. Our findings indicate that preoperative functional mitral regurgitation and postoperative aortic valve opening are related to the progression of AI during long-term LVAD support.
Background:Whether there is a significant difference in the long-term surgical outcomes between suture annuloplasty and ring annuloplasty for the treatment of functional tricuspid regurgitation (TR) ...is still controversial. We compared the long-term outcomes of tricuspid annuloplasty (TAP) with and without an annuloplasty ring.Methods and Results:From January 1996 to December 2015, we consecutively enrolled 684 patients (mean age, 65.5 years; 60% women) undergoing TAP for functional TR: 312 underwent conventional suture annuloplasty (Group S) and 372 underwent ring annuloplasty (Group R). Baseline characteristics were comparable between the 2 groups, except for age and the prevalence of prior cardiac surgery. The mean follow-up period was 7.3 years (range, 0.3–20.3 years).There was no significant difference in overall survival, freedom from major adverse cardiac and cerebrovascular events, and freedom from recurrent moderate to severe TR between Groups S and R, although postoperative mean TR grade and sPAP were significantly lower in Group R. Multivariate analysis revealed that age, prior cardiac surgery, and preoperative severe TR were independent predictors of recurrent moderate or greater TR.Conclusions:There was no significant difference in the long-term surgical outcomes between ring and suture TAP, although postoperative mean TR grade was lower in the ring annuloplasty group.
Background:Size-mismatched heart transplantation (HTx) is associated with a risk of stenosis of the caval anastomosis site or low cardiac output syndrome. We developed a modified bicaval anastomosis ...technique (mBCAT) that achieved an adjustable caval anastomosis to compensate for size mismatch. This study was performed to validate the rationale of the mBCAT for size-mismatched HTx.Methods and Results:This institutional consecutive series involved 106 patients who underwent HTx with the mBCAT during an 18-year period. The cohort was divided into 3 groups according to the donor-to-recipient body weight ratio: <0.8, undersized group (n=17); 0.8–1.3, size-matched group (n=68); and >1.3, oversized group (n=21); outcomes were compared. The undersized, size-matched, and oversized groups showed no significant differences in the rate of mild or worse echocardiographic tricuspid regurgitation at 1 month 1 (5.8%), 7 (10.2%), and 1 (4.8%), respectively; P=0.87 or the survival rate at 10 years 100%, 93.9%, and 100%, respectively; P=0.25. The right heart catheter study revealed no pressure gradient across the orifices of both cavae in any patient. Additionally, the cardiac index immediately post-HTx was significantly low in the undersized group (P=0.008), but was similar to the other groups at 6 months post-HTx (P=0.16).Conclusions:The mBCAT prevented caval anastomosis-related complications in size-mismatched HTx and achieved excellent hemodynamics regardless of donor size.
Background: The number of surgical aortic valve replacements using bioprosthetic valves is increasing, and newer bioprosthetic valves may offer clinical advantages in Japanese patients, who generally ...require smaller replacement valves than Western patients. In this study we retrospectively evaluated the Trifecta and Magna valves to compare clinical outcomes and hemodynamics in a group of Japanese patients. Methods and Results: Data were retrospectively collected for 103 patients receiving a Trifecta valve and 356 patients receiving a Magna valve between June 2008 and 2017. Adverse events, outcomes, and valve hemodynamics were evaluated. There were no significant differences in early or late outcomes between the Trifecta and Magna groups. In the early postoperative period, mean (±SD) pressure gradient (9.0±3.1 vs. 13.8±4.8 mmHg; P<0.01) and effective orifice area (1.68±0.46 vs. 1.46±0.40 m2; P<0.01) were significantly better for Trifecta, but the differences decreased over time. In particular, the interaction between time and valve type (Trifecta or Magna) was significantly different for mean pressure gradient between the 2 groups (P<0.01). Left ventricular mass regressed substantially in both groups, with no significant difference between them. There were no significant differences for severe patient-prosthesis mismatch. Conclusions: Postoperative outcomes were similar for both valves. An early hemodynamic advantage for the Trifecta valve lasted to approximately 1 year postoperatively but did not persist.
Infection during left ventricular assist device (LVAD) support is associated with a high mortality. This study investigated the effect of bloodstream infection on survival of patients with LVAD ...support and assessed risk factors for survival in LVAD patients with bloodstream infection.
Between 1999 and 2010, 109 consecutive patients with end-stage heart failure were supported by an LVAD as a bridge to transplantation. Overall survival was compared between those with and without a bloodstream infection. Risk factors for survival of patients with bloodstream infection were analyzed.
A bloodstream infection developed in 65 patients (60%) during 584 ± 389 days of LVAD support. Compared with patients without a bloodstream infection, overall survival was significantly worse in those with bloodstream infection (68% vs 84% at 2 years after LVAD implantation, p = 0.0117). However, of 22 patients bridged to transplantation, none had bloodstream infection recurrence after transplantation, and their 3-year survival rate after transplantation was 100%. Cox multivariate analysis (hazard ratio 95% confidence interval) identified postoperative right ventricular failure (2.890 1.238 to 6.757; p = 0.0141) and bloodstream infection caused by a pathogen other than gram-positive cocci (3.336 1.390 to 8.006 p = 0.0070) as significant risk factors for death in LVAD patients with a bloodstream infection.
Bloodstream infection had a significant effect on survival after LVAD implantation. Our results suggest that urgent cardiac transplantation should be considered for LVAD patients with a bloodstream infection based on the causative organism and right ventricular function.
Background:Transcatheter aortic valve implantation (TAVI) has become an alternative procedure for treating aortic stenosis (AS) in patients with advanced age and severe comorbidities. Ischemic heart ...disease (IHD) is present with AS in 40–50% of patients with typical angina. Considering the high operative mortality and morbidity rates in these patients, hybrid TAVI and off-pump CABG (OPCAB) have become realistic treatment options.Methods and Results:Between August 2014 and November 2015, 12 patients were evaluated for simultaneous TAVI and OPCAB. Because of their advanced age and comorbidities these patients were not considered suitable for standard open heart surgery. PCI was also considered unsuitable, because of left anterior descending artery (LAD) proximal lesions and/or high SYNTAX score. TAVI was conducted through a median sternotomy after left internal thoracic artery (LITA) to LAD anastomosis. In 11 cases OPCAB with LITA and composite RA graft was performed using an aorta no-touch technique. Mean age at operation was 81±6.3 years. Average number of distal anastomoses was 2.6. Perivalvular leakage was mild in 3 patients, trivial in 8, and none in 1. There was no conversion to on-pump procedure and no hospital deaths.Conclusions:Simultaneous transaortic TAVI and OPCAB in high-risk patients with severe AS and IHD is a reasonable option. This method could be an alternative to surgical aortic valve replacement and CABG. (Circ J 2016; 80: 1946–1950)
Background: In patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS), a sigmoid septum, characterized by subaortic interventricular hypertrophy, often ...results in the need for new pacemaker implantation (PMI). In this study, we reviewed the feasibility and treatment efficacy of TAVR for AS in patients with a sigmoid septum. Methods and Results: Between 2011 and 2016, 48 patients (25.4%; mean age 84.9±5.4 years; 9 males) with a sigmoid septum and 141 (74.6%; mean age 82.9±5.5 years; 61 males) without underwent TAVR. Their operative outcomes, echocardiographic and electrocardiographic findings, and long-term outcomes were retrospectively compared. Second TAVR because of valve malposition was performed in 3 patients with a sigmoid septum (6.3%) and in 2 patients without a sigmoid septum (1.4%), with no significant difference between the 2 groups. Although there was no significant difference in valve hemodynamics between the 2 groups, sigmoid septum and deep implantation (implantation depth ≥10 mm) were independent predictors of new PMI following TAVR. Conclusions: Although a sigmoid septum did not preclude the feasibility, safety, or efficacy of TAVR for severe AS, its presence was associated with new PMI. Our approach to TAVR in patients with a sigmoid septum may contribute to clinical outcomes comparable to those of patients without this pathology.
Purpose
A coronary artery aneurysm (CAA) can result in critical cardiac events such as thromboembolic complications or rupture. A saccular CAA located in the left main trunk (LMT) is the most ...critical form of this pathology and its surgical repair is challenging. We conducted this single-center study to review the surgical outcomes of patients with a saccular CAA in the LMT.
Methods
Between May, 2012 and June, 2020, five patients with a saccular CAA in the LMT underwent surgery at our center. The median age at operation was 66.5 (59.7–69) years and the median diameter of the CAA was 13.0 mm (IQR 11–14 mm).
Results
The CAA was fully excluded by patch closure of the LMT orifice and direct closure of the distal LMT, supplemented by coronary artery bypass grafting with the exclusive use of arterial conduits. There was no in-hospital mortality, although one patient suffered graft spasm-related myocardial infarction with complete recovery. Post-operative angiography showed a fully excluded LMT in all patients. There was no mortality or adverse cardiac events during follow-up.
Conclusions
Our surgical policy for CAA in the LMT is feasible and safe; however, coronary blood flow is dependent on reliable bypasses.
Objective
The effect of patient sex in continuous-flow ventricular assist device (c-VAD) therapy has not been well described. We investigated sex-specific differences in clinical outcomes related to ...c-VAD therapy for Japanese patients.
Methods
We retrospectively analyzed 153 patients, including 41 (27%) female patients who underwent c-VAD implantation over the last 13 years in our institution for a mean follow-up of 766 ± 446 days. Clinical outcomes were compared between male and female patients
Results
There was no significant difference in mortality, cerebral vascular accidents, the severity of heart failure, or driveline infection in patients who underwent c-VAD implantation, regardless of sex. While male patients tended to have more bleeding at the time of surgery, female patients had significantly higher rates of non-surgical bleeding during subsequent c-VAD therapy, mainly from gynecological origins.
Conclusions
Female patients treated with c-VAD had a significantly higher incidence of non-surgical bleeding events. Careful attention to gynecological complications and sex-specific care is required in female patients with c-VAD.
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