Risk stratification of best medical therapy for acute uncomplicated type B intramural hematoma.

OBJECTIVES: Best medical therapy (BMT) for acute uncomplicated type B intramural hematoma (TBIMH) is the current treatment guideline, but there is considerable controversy about subsequent clinical course and outcome, which may be associated with a significant failure rate. The purpose of this study was to identify potential risk factors for BMT failure and to develop a risk score to guide clinical decision making. METHODS: Patients with acute uncomplicated TBIMH between 2011 January and 2020 December were retrospectively studied. Logistic regression was applied to univariately assess potential risk predictors, and multivariable model results were then used to formulate a simplified predictive model for BMT failure. RESULTS: In a total of 61 patients, the overall rate of BMT failure was 57.4% (35/61), of which 48.6% (17/35) occurred within 28 days of onset. Logistic regression identified maximum descending aortic diameter (HR â€‹= â€‹1.99 CI â€‹= â€‹1.16-3.40, p â€‹= â€‹0.012), initial IMH thickness (HR â€‹= â€‹3.29, CI â€‹= â€‹1.28-8.46, p â€‹= â€‹0.013) and presence of focal contrast enhancement (HR â€‹= â€‹3.12, CI â€‹= â€‹1.49-6.54, p â€‹= â€‹0.003) as potential risk predictors of BMT failure. A risk score was calculated as follows: [Max DTA diameter (mm)∗0.6876 â€‹+ â€‹Max IMH thickness (mm)∗1.1918 â€‹+ â€‹PAU/ULP ∗1.1369]. Freedom from BMT failure at 1 year was 72% in patients with a risk score â€‹< â€‹4.12, compared with only 35.1% in those with a risk score â€‹â‰§ â€‹4.12. CONCLUSIONS: In a substantial proportion of patients with acute uncomplicated TBIMH, initial BMT failed. Based on the three initial computed tomographic imaging variables, this risk score could help stratify patients at high or low risk for BMT failure and provided additional information for early intervention.

Selective placement of novel compression suture technique to reduce pacemaker implantation rate following surgical aortic valve replacement with rapid deployment INTUITY valve.

OBJECTIVE: The use of RDV in SAVR is associated with risk of conduction abnormality requiring PPM implantation, when compared to conventional bioprosthetic valves. We aimed to evaluate the outcome after selective placement of annular compression sutures during surgical aortic valve replacement (SAVR) using Intuity rapid deployment valve (RDV). METHODS: This is a retrospective study of prospectively enrolled patients receiving SAVR using Intuity RDV. Selective placement of commissural compression suture was assessed for all patients based on their annular morphology. Outcomes including operative mortality, rate of pacemaker rate, paravalvular leak and change in trans-valvular pressure gradient were analyzed. RESULTS: 56 consecutive patients underwent SAVR with the INTUITY RDV at our institution from January 2020 to November 2021. The Mean age of our cohort was 69.9 ± 10.6 years with a EuroSCORE II of 3.4 ± 2.4%. 28.6% (16/56) of patients had notable conduction abnormalities pre-operatively, which included atrial fibrillation and left/right bundle branch block. Compression sutures were selectively applied in 19/56 (33.9%) patients. Of which, 13 were bicuspid aortic valve. Post-operatively, we observed no conduction abnormality requiring PPM implantation. In addition, only 3 of the 56 (5.4%) had any degree of paravalvular leak on post-operative echocardiography (all ≤ mild). The mean reduction in trans-valvular gradient was 29.9 mmHg and the mean pressure gradient at 1 month and 1 year follow-up were 9.3 ± 3.6 mmHg and 10.2 ± 4.1 mmHg, respectively. CONCLUSIONS: Selective placement of compression suture helps to avoid unnecessary oversizing, which may reduce the risk of paravalvular leak and post-operative PPM implantation.

End-stage renal disease should not Be considered a contraindication for veno-arterial extracorporeal membrane oxygenation.

PURPOSE: This study aims to determine whether end-stage renal disease (ESRD) is a true contraindication for extracorporeal membrane oxygenation in adult patients. MATERIALS AND METHODS: Adult patients who received VA-ECMO at National Taiwan University Hospital between January 2010 and December 2021 were included. Patients who received regular dialysis before the index admission were included in the ESRD group. The primary outcome was in-hospital mortality. RESULTS: 1341 patients were included in the analysis, 121 of whom had ESRD before index admission. The ESRD group was older (62.3 versus 56.8 years; P < 0.01) and had more comorbidities. Extracorporeal cardiopulmonary resuscitation (ECPR) was used more frequently in the ESRD group (66.1% versus 51.6%; P < 0.001). The ESRD group had higher in-hospital mortality rates (72.7% versus 63.3%; P = 0.03). In the ECPR subgroup, there was no difference of survival between ESRD and others(P = 0.56). In the multivariate Cox regression, ESRD was not an independent predictor for mortality (P = 0.20). CONCLUSIONS: ESRD was not an independent predictor of in-hospital mortality after VA-ECMO. The survival of ESRD patients was not inferior to those without ESRD when receiving ECPR. Therefore, ESRD should not be considered a contraindication to VA-ECMO in adults.

Computer-assisted image analysis of preexisting histological patterns of the cephalic vein to predict wrist arteriovenous fistula non-maturation.

BACKGROUND: We used computer-assisted image analysis to determine whether preexisting histological features of the cephalic vein influence the risk of non-maturation of wrist fistulas. METHODS: This study focused on patients aged 20-80 years who underwent their first wrist fistula creation. A total of 206 patients participated, and vein samples for Masson's trichrome staining were collected from 134 patients. From these, 94 patients provided a complete girth of the venous specimen for automatic image analysis. Maturation was assessed using ultrasound within 90 days after surgery. RESULTS: The collagen to muscle ratio in the target vein, measured by computer-assisted imaging, was a strong predictor of non-maturation in wrist fistulas. Receiver operating characteristic analysis revealed an area under the curve of 0.864 (95% confidence interval of 0.782-0.946, p < 0.001). The optimal cut-off value for the ratio was 1.138, as determined by the Youden index maximum method, with a sensitivity of 89.0% and specificity of 71.4%. For easy application, we used a cutoff value of 1.0; the non-maturation rates for patients with ratios >1 and ≤ 1 were 51.7% (15 out of 29 patients) and 9.2% (6 out of 65 patients), respectively. Chi-square testing revealed significantly different non-maturation rates between the two groups (X2 (1, N = 94) = 20.9, p < 0.01). CONCLUSION: Computer-assisted image interpretation can help to quantify the preexisting histological patterns of the cephalic vein, while the collagen-to-muscle ratio can predict non-maturation of wrist fistula development at an early stage.

Impact of Previous Conventional Cardiac Surgery on the Clinical Outcomes After Heart Transplantation.

The impact of the type, purpose, and timing of prior surgery on heart transplantation (HT) remains unclear. This study investigated the influence of conventional cardiac surgery (PCCS) on HT outcomes. This study analyzed HTs performed between 1999 and 2019 at a single institution. Patients were categorized into two groups: those with and without PCCS. Short-term outcomes, including post-transplant complications and mortality rates, were evaluated. Cox proportional and Kaplan-Meier survival analyses were used to identify risk factors for mortality and assess long-term survival, respectively. Of 368 patients, 29% had PCCS. Patients with PCCS had a higher incidence of post-transplant complications. The in-hospital and 1 year mortality rates were higher in the PCCS group. PCCS and cardiopulmonary bypass time were significant risk factors for 1 year mortality (hazard ratios = 2.485 and 1.005, respectively). The long-term survival rates were lower in the PCCS group, particularly in the first year. In sub-analysis, patients with ischemic cardiomyopathy and PCCS had the poorest outcomes. The era of surgery and timing of PCCS in relation to HT did not significantly impact outcomes. In conclusion, PCCS worsen the HT outcomes, especially in patients with ischemic etiology. However, the timing of PCCS and era of HT did not significantly affect this concern.

Role of percutaneous pulmonary artery cannulation in extracorporeal life support for acute cardiac failure: A single-center case series.

BACKGROUND: Pulmonary artery (PA) cannulation is an effective extracorporeal life support (ECLS) management for left ventricular (LV) decompression or right ventricular (RV) support. This case series explores the results of PA cannulation during ECLS for acute cardiac failure. METHODS: Patients receiving percutaneous PA cannulation between January 2017 and December 2020 in a single institution were retrospectively reviewed. Patients receiving PA cannulation by a surgical cutdown method were excluded. Based on the hemodynamic needs of the patients, percutaneous PA cannulation was applied with ECLS for LV unloading and/or RV support. The primary endpoint was the successful weaning from circulatory support. The secondary endpoints included 30-day or in-hospital mortality, significant periprocedural complications, and successful hospital discharge without major complications. RESULTS: Fifteen patients (13 men, age range 11.2-70.8 years) presented acute heart failure and were initially managed by conventional ECLS mode. Percutaneous PA cannulation was performed for LV unloading in 13 patients (86.67%) and isolated RV circulatory support in two patients (13.33%). Weaning from circulatory support was achieved in 11 patients (73.33%). No significant periprocedural complication, including bleeding, infection, or vascular event requiring surgical exploration, was reported. The 30-day or in-hospital mortality rate was 33.33%. Eight cases (53.33%) were successfully discharged without major complications, including permanent stroke or the need for long-term hemodialysis. CONCLUSIONS: PA cannulation, especially percutaneously performed, was effective and safe for LV unloading and/or RV support during ECLS. Further investigation is required to confirm the efficacy and safety of our approach and management in a larger patient population.

Validation of the European system for cardiac operative risk evaluation II in a large Taiwan cardiac surgical centre.

BACKGROUND: The European System for Cardiac Operative Risk Evaluation (EuroSCORE II) is a well-established scoring system for predicting mortality in cardiac surgery. This system was derived predominantly from a European patient cohort; however, no validation of this system has been conducted in Taiwan. We sought to assess the performance of EuroSCORE II at a tertiary centre. METHODS: The 2161 adult patients receiving cardiac surgery between 2017 and 2020 in our institution were included. RESULTS: Overall, the in-hospital mortality rate was 7.89%. The performance of EuroSCORE II was assessed using the area under the receiver operator curve (AUC) for discrimination and the Hosmer-Lemeshow (H-L) test for calibration. Data were analysed for type of surgery, risk stratification, and status of the operation. EuroSCORE II had good discriminative power (AUC=0.854, 95% Confidence Interval (CI): 0.822-0.885) and good calibration (χ2=5.19, p=0.82) for all types of surgery except ventricular assist devices (AUC=0.618, 95% CI: 0.497-0.738). EuroSCORE II also showed good calibration for most types of surgery except coronary artery bypass surgery (CABG) combined procedure (P=0.033), heart transplantation (HT) (P=0.017), and urgent operation (P=0.041). EuroSCORE II significantly underestimated the risk for CABG combined procedure and urgent operations, and overestimated the risk for HT. CONCLUSION: EuroSCORE II had satisfactory discrimination and calibration power to predict surgical mortality in Taiwan. However, the model is poorly calibrated for CABG combined procedure, HT, urgent operation, and, likely, lower- and higher-risk patients.

Impact of duration of mechanical support on heart transplantation: Hasty transplantation may not have a good long-term outcome.

BACKGROUND: Mechanical circulatory support (MCS) has been widely utilized in critically ill cardiac transplant candidates. Few studies have investigated the impact of duration of MCS before heart transplantation (HTx) on long-term patient survival. METHODS: A retrospective HTx database was reviewed between 2009 and 2019. Patients who did not or did undergo MCS before HTx were categorized into two groups: (1) A (did not) and (2) B (did), respectively. A receiver operating characteristic (ROC) curve was plotted to assess the cutoff level of MCS duration before HTx in evaluating 5-year survival. RESULT: A total of 270 HTx patients (group A: 120, group B: 150) were analyzed. Group B patients had a higher percentage of blood type O, a higher incidence of resuscitation, a shorter listing duration, and a higher likelihood of having United Network for Organ Sharing (UNOS) 1A status than group A. The ROC curve revealed 24 days as a good cut-off level for determining the best MCS before HTx timing. Group B was categorized into two subgroups: (1) B1 (MCS < 24 days, n = 65) and (2) B2 (MCS > 24 days, n = 85). B2 had a higher incidence of cardiopulmonary resuscitation (CPR), hemodialysis, longer waiting time after MCS, and better ventricular assist device implantation than B1. However, the survival curves showed that B1 outcomes were significantly worse than in groups A and B2. Groups A and B2 had similar survival curves without an increased incidence of infection. CONCLUSION: The preliminary data demonstrated that a longer duration of MCS may be associated with better outcomes than urgent HTx.

Impact of Pretransplant Renal Replacement Therapy on Clinical Outcome After Isolated Heart Transplantation.

End stage renal disease (ESRD) is a contraindication to isolated heart transplantation (HT). However, heart candidates with cardiogenic shock may experience acute kidney injury and require renal replacement therapy (RRT) and isolated HT as a life-saving operation. The outcomes, including survival and renal function, are rarely reported. We enrolled 569 patients undergoing isolated HT from 1989 to 2018. Among them, 66 patients required RRT before HT (34 transient and 32 persistent). The survival was worse in patients with RRT than those without (65.2% vs 84.7%; 27.3% vs 51.1% at 1- and 10-year, p < 0.001 and p = 0.012, respectively). Multivariate Cox analysis identified pre-transplant hyperbilirubinemia (Hazard ratio (HR) 2.534, 95% confidence interval (CI) 1.098-5.853, p = 0.029), post-transplant RRT (HR 5.551, 95%CI 1.280-24.068, p = 0.022) and post-transplant early bloodstream infection (HR 3.014, 95%CI 1.270-7.152, p = 0.012) as independent risk factors of 1-year mortality. The majority of operative survivors (98%) displayed renal recovery after HT. Although patients with persistent or transient RRT before HT had a similar long-term survival, patients with persistent RRT developed a high incidence (49.2%) of dialysis-dependent ESRD at 10 years. In transplant candidates with pretransplant RRT, hyperbilirubinemia should be carefully re-evaluated for the eligibility of HT whereas prevention and management of bloodstream infection after HT improve survival.

Impact of pre-transplant bloodstream infection on clinical outcomes after heart transplantation.

BACKGROUND: Active bloodstream infection (BSI) is a contraindication for heart transplantation (HT). However, some critical patients with BSI may undergo HT as a life-saving procedure. We aimed to investigate the impact of pre-transplant BSI on the clinical outcomes after HT. METHODS: We enrolled 511 consecutive patients who underwent HT between 1999 and 2019. Patients were divided into two groups based on the presence of BSI within 30 days preoperatively. Forty-three patients (8.4%) with BSI who were clinically stable and had no metastatic infection were considered for HT on an individual basis. In-hospital mortality, incidence of early postoperative BSI, length of postoperative hospital stays, and long-term survival were compared between the groups. Logistic and Cox regression analyses were performed to identify risk factors for in-hospital and 1-year mortality. RESULTS: Patients with pre-transplant BSI had a high incidence of previous cardiopulmonary resuscitation, pre-transplant ventilator use, mechanical circulatory support use, renal replacement therapy, United Network for Organ Sharing status 1A, and a prolonged preoperative hospital waiting period. The in-hospital mortality rate was higher in patients with pre-transplant BSI (21% vs. 12%, p = .081), and the mortality rate was very high (33.3%) for those with BSI 0-15 days before HT. In addition, patients with pre-transplant BSI had a significantly longer postoperative hospital stay than patients in the control group. However, long-term survival was similar in both groups. CONCLUSIONS: Although pre-transplant BSI was associated with higher in-hospital mortality and prolonged postoperative hospital stay, patients who survived the early period had a similar long-term prognosis.

Aortic remodeling after endovascular aortic repair and tailored distal entry tears exclusion in Crawford type III or IV dissection aneurysm.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) can only promote 55-80% false lumen (FL) thrombosis when only the proximal primary tear is covered during the repair of type B aortic dissection (TBAD). This study evaluated the effectiveness and clinical outcome of tailored exclusion of the primary entry tear with TEVAR and distal fenestrations with ancillary devices in patients with subacute or chronic Crawford type III and IV aortic dissection aneurysm. METHODS: All patients underwent either TEVAR for primary entry tear; subsequently, various ancillary devices were applied on each distal fenestration. These techniques included covered stent occlusion of detached visceral artery entry tears, TL stenting and FL occlusion with vascular plugs in the common iliac artery dissection, or TEVAR coverage for multiple fenestrations from segmental arteries. This case series included nine patients (seven men and two women; mean age: 63.4 years) during January 2013 to May 2019. Outcome analysis included the rates of technical success and procedure-related complications, completeness of FL occlusion, aortic remodeling, and midterm mortality at 2 years. RESULTS: The mean follow-up duration was 37.7 months without in-hospital mortality. One patient was lost to follow-up at the second month, the rest of patients were all alive during the follow-up period. All patients achieved complete FL thrombosis, and six patients exhibited aneurysm diameter shrinkage. CONCLUSION: Tailored exclusion of visceral and iliac distal fenestrations with proximal primary tear coverage can promote FL thrombosis and aortic remodeling in the visceral aortic segment in patients with Crawford type III or IV aortic dissection aneurysm.

Comparison of robotic and conventional sternotomy in redo mitral valve surgery.

BACKGROUND/PURPOSE: Redo operation for mitral valve surgery carries higher risks than first time cardiac surgery. The adhesion between sternum and heart, and also the complexity of second time operation make the redo operation more difficult. The robotic surgery carries some benefit in terms of magnification, assisted by the scope view and precise movement of the instruments. We compared the results of our robotic redo mitral valve surgeries with those of conventional re-sternotomy. METHODS: Medical records of patients who underwent redo mitral valve surgeries between 2012 and 2019 at our hospital were retrospectively analyzed. Demographic data, patients' medical histories, presenting symptoms, image analyses, echocardiogram data, operative procedures and postoperative clinical outcomes were collected through chart review. RESULTS: A total of 67 redo mitral valve surgeries, including 23 robotic and 44 re-sternotomy procedures were performed. There were no differences in age, previous operation times, and intervals to previous surgery. Comorbidities of both groups were similar. There was no surgical mortality in the robotic group, and it was 9.0% in the re-sternotomy group (p = 0.287). Operation time was shorter in the robotic group (176 vs. 321 min; robotic vs. re-sternotomy, p＝0.0279). Blood transfusion was lower in the robotic group (1 vs. 2 units; robotic vs. re-sternotomy, p = 0.01189). The ventilation time, ICU stay time, and recheck bleeding rate were similar in both groups. CONCLUSION: In select patients, robotic redo mitral valve surgery is safe and feasible. It could offer low operative mortality. It is associated with shorter operative times, than re-sternotomy and provides equal immediate operative results.

Outcome of urgent desensitization in sensitized heart transplant recipients.

BACKGROUND/PURPOSE: Sensitization, the presence of preformed anti-human antibody in recipients, restricts access to ABO-compatible donors in heart transplant. Desensitization therapy works by reducing preformed antibodies to increase the chances of a negative crossmatch or permit safe transplantation across positive crossmatch. There is no consensus regarding the desensitization protocol in cardiac patients, and the outcome of desensitization remains under debate. METHODS: Twenty-five consecutive sensitized heart transplant recipients received perioperative desensitization in our institution from 2012 to 2019. One-year patient survival and graft rejection rate were analyzed and compared between sensitized recipients and non-sensitized recipients. RESULTS: Within the first year after transplant, patient survival in sensitized recipients was 76%. Infection was the major cause of death. The cumulative incidence of rejection was 8% for antibody-mediated rejection and 16% for acute cellular rejection. No significant difference in 1-year survival or rejection rate could be demonstrated between sensitized and nonsensitized recipients. CONCLUSION: Acceptable early outcomes in patient survival and graft rejection could be anticipated in sensitized heart transplant recipients under a perioperative algorithm using complement-dependent cytotoxicity crossmatch- or panel-reactive antibody-directed urgent immunomodulation strategies, while infection remains the major concern.

Effects of Slowness, Frailty, Insufficient Intake, and Delirium in Patients Following Cardiac Surgery: A Cohort Study.

BACKGROUND: Slow gait, frailty, insufficient postoperative caloric intake, and delirium, although seemingly distinct, can appear simultaneously in patients who underwent cardiac surgery. OBJECTIVES: The aim of this study was to evaluate how these 4 factors overlap and how they individually and cumulatively affect cardiac surgery outcomes. METHODS: The effects of slowness (gait speed <0.83 m/s), frailty (≥3/5 Fried criteria), insufficient postoperative intake (<800 kcal/d), and delirium (defined by the Confusion Assessment Method) on hospital length of stay (LOS) and 3-month mortality were analyzed in 308 adult patients. RESULTS: Slowness, frailty, insufficient intake, and delirium affected 27.5%, 29.5%, 31.5%, and 13.3% of participants, respectively; only 42.2% (130/308) were free from these risks. Risk overlap was prevalent, as 26.3% (n = 81) had 2 or more risk factors. The most obvious overlap was in delirium (80% of delirious participants had other risks), suggesting that delirium cannot be managed in isolation. Individually, whereas slowness was associated only with longer LOS, frailty, insufficient intake, and delirium all led to longer LOS and higher mortality. When equally weighting each risk factor to analyze their cumulative effects, LOS increased by 4.4 days (95% confidence interval, 3.0-5.7) and 3-month mortality increased by 2.6-fold (95% confidence interval, 1.4-4.6), with each risk factor added, independent of participants' educational level, body mass index, and risk for cardiac surgery (EuroSCORE II ≥6). CONCLUSIONS: Because a clinical overlap of slowness, frailty, insufficient postoperative intake, and delirium was evident in patients who underwent cardiac surgery, and risk of death and longer hospital stay increased with each factor added, care should be revised to consider these overlapping factors to maximize patient outcomes.

Outcome for surgical treatment of infective endocarditis with periannular abscess.

BACKGROUND: Surgical treatment of infective endocarditis (IE) with aortic periannular abscess (PA) is a challenging issue with high mortality and morbidity rate in the current era. The present study is to review the results of surgical treatment for IE-PA based on an anatomy-guided surgical procedure selection for either aortic valve replacement (AVR) or aortic root reconstruction (ARR). METHODS: Patients with IE-PA received surgical treatment in National Taiwan University Hospital during the years 2001-2017 were retrospectively reviewed. The selection of surgical procedure was based on the intraoperative anatomical finding. The AVR group consisted of isolated AVR or AVR with patch repair if PA involved less than one cusp of the annulus. The ARR group included aortic root replacement if PA involved more than one cusp, causing commissural/sub-commissural destruction. In-hospital mortality and mid-term outcome and the risk factors were examined. RESULTS: In-hospital mortality was 13% in the AVR group (24 patients) and 25% in the ARR group (8 patients) (p = 0.578). The composite adverse events (cardiac death, valve reoperation, or paravalvular leak) rate was 31% in the AVR group and 40% in the ARR group at one year; 48% in the AVR group and 40% in the ARR group at five years; 55% in the AVR group and 40% in the ARR group at ten years. CONCLUSION: Anatomy-guided surgical procedure selection for IE-PA is feasible. With the appropriate selection, ARR may be associated with fewer adverse events in mid-term follow-up. Careful intraoperative judgment and management and long-term follow-up are warranted for these patients.

2019 Focused Update of the Guidelines of the Taiwan Society of Cardiology for the Diagnosis and Treatment of Heart Failure.

Heart failure is a growing epidemic, especially in Taiwan because of the aging population. The 2016 Taiwan Society of Cardiology - Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry showed that the guideline-recommended therapies were prescribed suboptimally both at the time of hospital discharge and during follow-up. We, therefore, conducted this 2019 focused update of the guidelines of the Taiwan Society of Cardiology for the diagnosis and treatment of heart failure to reinforce the importance of new diagnostic and therapeutic modalities of heart failure. The 2019 focused update discusses new diagnostic criteria, pharmacotherapy, non-pharmacological management, and certain co-morbidities of heart failure. Angiotensin receptor neprilysin inhibitor and If channel inhibitor is introduced as new and recommended medical therapies. Latest criteria of cardiac resynchronization therapy, implantable cardioverter-defibrillator, heart transplantation, and ventricular assist device therapy are reviewed in the non-pharmacological management chapter. Co-morbidities in heart failure are discussed including chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and sleep-disordered breathing. We also explain the adequate use of oxygen therapy and non-invasive ventilation in heart failure management. A particular chapter for chemotherapy-induced cardiac toxicity is incorporated in the focused update to emphasize the importance of its recognition and management. Lastly, implications from the TSOC-HFrEF registry and post-acute care of heart failure are discussed to highlight the importance of guideline-directed medical therapy and the benefits of multidisciplinary disease management programs. With guideline recommendations, we hope that the management of heart failure can be improved in our society.

Do Patients With High CHA2DS2-VASc Scores Need High Intensity of Anticoagulants After Valve Surgery?

BACKGROUND: Asian patients on warfarin therapy usually have lower international normalized ratio (INR) intensities than those recommended by Western clinical practice guidelines. This study evaluated whether a high INR reduces the incidence of thromboembolism (TE) or bleeding events in Asian patients with high CHA2DS2-VASc scores after valve surgery.Methods and Results:Data of adult patients after valve surgery were retrieved from an integrated healthcare information system of a single hospital between 2014 and 2016. The INR was derived from the closest laboratory data before the index outpatient-clinic visit date. The endpoint of every record was determined as emergency room visit or hospitalization because of TE or bleeding event. A total of 37 TE or bleeding events were retrieved from 8,207 records; the annual incidence rate were 1.2% and 2.8% for low (0-2) and high (3-8) CHA2DS2-VASc score groups, respectively (P=0.007). The incidence rates were lowest for both groups at an INR of 1.5-2.0. High INR intensities did not reduce TE or bleeding incidence. INR >3.0 was associated with increased TE or bleeding incidence in the high-score group (6.8%/year vs. 2.0%/year, P=0.079). CONCLUSIONS: The optimal INR is 1.5-2.5 for low- or high-score Asian patients after valve surgery. INR >3.0 was associated with increased TE or bleeding incidence in the high-score group.

Robotic Transmitral Approach for Hypertrophic Cardiomyopathy With Systolic Anterior Motion.

BACKGROUND: Surgical intervention is indicated in symptomatic hypertrophic cardiomyopathy (HCM) patients with a ventricular outflow pressure gradient more than 50 mmHg. The transmitral approach, along with the transapical and transaortic approaches, is routinely used for myectomy, but all are open procedures. We describe a robotic transmitral approach that can be used to resolve septal hypertrophied muscle and eliminate mitral regurgitation (MR) using 1 cardiac incision. Methods and Results: We retrospectively analyzed 20 adult patients with obstructive HCM who exhibited concomitant severe MR and systolic anterior motion (SAM). The 2 groups comprised 12 standard full-sternotomy transaortic and 8 robotic transmitral approaches. The pre-intraventricular pressure gradient was 69±14.2 mmHg in the robotic transmitral group and 70.2±17.4 mmHg in the transaortic group (P=0.876). Both groups had a similar left ventricular ejection fraction (65±8% vs. 72±9%, P=0.901) and maximal ventricular wall thickness (22.3±4.5 and 21.7±6.0, P=0.835). Postoperative MR was reduced to less than grade II in all patients. In the robotic group, the postoperative pressure gradient was 1.5±2.6 mmHg, which was lower than that of the transaortic group at 10.6±10.8 mmHg (P=0.019). The cross-clamp time was 95.3±7.7 min in the robotic group and 104.7±20.8 min in the transaortic group (P=0.193). The operation time was 237.5±22.4 and 309.6±28.5 min (P<0.01) in the robotic transmitral and transaortic groups, respectively. CONCLUSIONS: Using a robotic transmitral approach to treat with patients with HCM, SAM, and MR is feasible and reliable. Through 1 atrial incision, it is possible to resolve hypertrophy of the septum and eliminate both severe MR and SAM.

Urinary biomarkers predict advanced acute kidney injury after cardiovascular surgery.

BACKGROUND: Acute kidney injury (AKI) after cardiovascular surgery is a serious complication. Little is known about the ability of novel biomarkers in combination with clinical risk scores for prediction of advanced AKI. METHODS: In this prospectively conducted multicenter study, urine samples were collected from 149 adults at 0, 3, 6, 12 and 24 h after cardiovascular surgery. We measured urinary hemojuvelin (uHJV), kidney injury molecule-1 (uKIM-1), neutrophil gelatinase-associated lipocalin (uNGAL), α-glutathione S-transferase (uα-GST) and π-glutathione S-transferase (uπ-GST). The primary outcome was advanced AKI, under the definition of Kidney Disease: Improving Global Outcomes (KDIGO) stage 2, 3 and composite outcomes were KDIGO stage 2, 3 or 90-day mortality after hospital discharge. RESULTS: Patients with advanced AKI had significantly higher levels of uHJV and uKIM-1 at 3, 6 and 12 h after surgery. When normalized by urinary creatinine level, uKIM-1 in combination with uHJV at 3 h post-surgery had a high predictive ability for advanced AKI and composite outcome (AUC = 0.898 and 0.905, respectively). The combination of this biomarker panel (normalized uKIM-1, uHJV at 3 h post-operation) and Liano's score was superior in predicting advanced AKI (AUC = 0.931, category-free net reclassification improvement of 1.149, and p <  0.001). CONCLUSIONS: When added to Liano's score, normalized uHJV and uKIM-1 levels at 3 h after cardiovascular surgery enhanced the identification of patients at higher risk of progression to advanced AKI and composite outcomes.

Long-term outcomes of surgical treatment for intravascular leiomyomatosis.

BACKGROUND: Intravascular leiomyomatosis (IVL) is relatively rare. The optimal surgical method and long-term outcomes are not completely understood. METHODS: Medical records between 2007 and 2017 in our hospital were analyzed to identify IVL cases with surgical intervention. Their medical records, operative details, and follow-up were collected by chart review and telephone communication. RESULTS: Eight patients with IVL were included in the study, accounting for 0.26% of all uterine leiomyoma cases. Primary IVL was confined to pelvic cavity in three patients, extended to the inferior vena cava (IVC) below renal vein in one, reached IVC and right atrium in three, and reached main pulmonary artery in one. One-stage operation was performed for seven patients. Cardiopulmonary bypass was done in four patients, and aortic cross-clamp and temporary circulatory arrest was performed in two patients. None of the four patients with intrapulmonary tumors received concomitant pulmonary tumor resection. There was no operative mortality and four morbidities, including ureter injury (2), bladder injury (1), and femoral vein thrombosis (1). During follow-up, two patients exhibited local recurrence of the tumor in the pelvis, and one patient had rapidly growing intrapulmonary tumor three months post-operatively. Intrapulmonary tumors in the other three patients remained stationary at 6, 84, and 120 months post-operatively. CONCLUSION: One-stage operation to completely remove IVL is feasible and with good long-term outcomes, which is recommended if the patient can tolerate the operation. Concomitant intrapulmonary tumors can be followed up watchfully except when associated with pleural effusion or the pathology indicating trend of increasing malignancy.