A novel approach for the endothelialization of xenogeneic decellularized vascular tissues by human cells utilizing surface modification and dynamic culture.

Decellularized xenogeneic vascular grafts can be used in revascularization surgeries. We have developed decellularization methods using high hydrostatic pressure (HHP), which preserves the extracellular structure. Here, we attempted ex vivo endothelialization of HHP-decellularized xenogeneic tissues using human endothelial cells (ECs) to prevent clot formation against human blood. Slices of porcine aortic endothelium were decellularized using HHP and coated with gelatin. Human umbilical vein ECs were directly seeded and cultured under dynamic flow or static conditions for 14 days. Dynamic flow cultures tend to demonstrate higher cell coverage. We then coated the tissues with the E8 fragment of human laminin-411 (hL411), which has high affinity for ECs, and found that Dynamic/hL411showed high area coverage, almost reaching 100% (Dynamic/Gelatin vs Dynamic/hL411; 58.7 ± 11.4 vs 97.5 ± 1.9%, P = 0.0017). Immunostaining revealed sufficient endothelial cell coverage as a single cell layer in Dynamic/hL411. A clot formation assay using human whole blood showed low clot formation in Dynamic/hL411, almost similar to that in the negative control, polytetrafluoroethylene. Surface modification of HHP-decellularized xenogeneic endothelial tissues combined with dynamic culture achieved sufficient ex vivo endothelialization along with prevention of clot formation, indicating their potential for clinical use as vascular grafts in the future.

En bloc excision of giant polycystic liver with hepatic cava and its auto-transplant caval reconstruction as a safe surgical procedure for liver transplantation.

Safely excising a giant liver while leaving the hepatic inferior vena cava intact is difficult. Hata et al. present images and videos describing their novel technique consisting of total hepatectomy including the hepatic cava; extracorporeal retrieval; and auto-transplant inferior vena cava reconstruction, for an extremely enlarged polycystic liver weighing 24 kg.

Single-stage repair of the right aortic arch with Kommerell diverticulum through the right thoracotomy with SIRC approach.

Kommerell diverticulum (KD) is a congenital vascular disease associated with dilatation at an aberrant subclavian artery's origin. The surgical repair should be considered for the symptomatic patients due to the adjacent organ's compression by the aneurysmal change of KD. An appropriate approach should be selected for the open repair to suit the anatomical type of disease. We reported a 50-year-old female diagnosed with KD undergoing the single-stage open repair through the right thoracotomy with the straight skin incision with rib cross.

[One-stage Radical Surgery for Aortoesophageal Fistula after Graft Replacement of Descending Aorta].

A 31-year-old woman was referred to our institution because of aortoesophageal fistula (AEF) six months after the descending aortic replacement for acute aortic dissection. We operated one-stage repair of the AEF. Thoracoscopic esophagectomy was firstly performed in prone position from right thoracic cavity, and then the esophagus was reconstructed with gastric conduit via posterior mediastinal route with omental flap. Secondly, graft replacement of the descending aorta using lateral oblique straight incision was performed and the graft was covered with omental flap simultaneously. The postoperative course was uneventful, and she started oral intake on the 13th day after surgery. Although the one-stage surgery for the AEF is highly invasive, it could be a good option for selected cases.

[Initial Experiences of Valve-sparing Aortic Root Replacement Using New Designed Valsalva Graft:Report of Three Cases].

Valve sparing aortic root replacement( VSRR) is currently an established option for patients with annuloaortic ectasia( AAE). A newly designed Valsalva graft, the J Graft Shield Neo Valsalva, was used for VSRR in three cases. All operations were successful and postoperative courses were uneventful. Graft designs closer in shape to the native Valsalva may contribute to the improvement of late outcomes in VSRR.

Pharmacist-physician collaborative care for outpatients with left ventricular assist devices using a cloud-based home medical management information-sharing system: a case report.

BACKGROUND: The standard anticoagulation therapy for patients implanted with left ventricular assist devices (LVADs) includes warfarin therapy. We developed a cloud-based home medical management information-sharing system named as LVAD@home. The LVAD@home system is an application designed to be used on iPad tablet computers. This system enables the sharing of daily information between a patient and care providers in real time. In this study, we reported cases of outpatients with LVADs using this system to manage anticoagulation therapy. CASE PRESENTATION: The patient, a man in his 40s with end-stage heart failure owing to non-ischemic dilated cardiomyopathy, underwent LVAD implantation and warfarin was started on postoperative day 1. He started to use LVAD@home to manage warfarin therapy after discharge (postoperative day 47). He sent his data to care providers daily. By using this system, the pharmacist observed his signs of reduced dietary intake 179 days after discharge, and after consulting the physician, told the patient to change the timing of the next measurement earlier than usual. On the next day, the prothrombin time-international normalized ratio increased from 2.0 to 3.0, and thus the dose was decreased by 0.5 mg. Four patients used this system to monitor warfarin therapy from October 2015 to March 2018. In these patients, the time in therapeutic range was 90.1 ± 1.3, which was higher than that observed in previous studies. Additionally, there were no thromboembolic events or bleeding events. CONCLUSIONS: The cloud-based home management system can be applied to share real-time patient information of factors, including dietary intake that interact with warfarin. It can help to improve long-term anticoagulation outcomes in patients implanted with LVAD.

A case of aggressive aortic prosthetic valve endocarditis aggressive caused by Staphylococcus lugdunensis.

BACKGROUND: Staphylococcus lugdunensis is a coagulase-negative Staphylococcus species, which are weak pathogenic bacteria generally. However, the acute and severe pathogenicity of Staphylococcus lugdunensis infective endocarditis may be due to the rapid growth of large vegetation and consequent valve destruction. CASE PRESENTATION: The patient was an 81-year-old male who visited our hospital with chief complaints of low back pain and high fever. Four years before this visit, he had undergone aortic valve replacement for aortic regurgitation. He was found to be hypotensive. Although there is no heart murmur on auscultation and echocardiography revealed negative findings with aortic valve, a blood test showed increases in the white blood cell count and C-reactive protein concentration. On the next day, Gram-positive cocci were detected in a blood culture and echocardiography detected a large vegetation on the prosthetic valve with increased flow velocity. Therefore, he underwent redo aortic valve replacement emergently. Staphylococcus lugdunensis was identified in blood samples and vegetation culture. Consequently, the patient was treated with antibiotics for 5 weeks after the operation and discharged home. CONCLUSIONS: We experienced rapidly progressive prosthetic valve endocarditis caused by Staphylococcus lugdunensis. Hence, Staphylococcus lugdunensis infective endocarditis requires aggressive treatment, and the pathogenicity of this coagulase-negative Staphylococcus with high drug susceptibility should not be underestimated.

[Valve-sparing Root Reimplantation for Stanford Type A Acute Aortic Dissection Combined with Aortic Root Dilation and Bicuspid Aortic Valve;Report of a Case].

A 45-year-old male developed Stanford type A acute aortic dissection combined with aortic root dilation and congenital bicuspid aortic valve (BAV). He had a Sieveres type 0 BAV, lateral subtype with right and left cusps. Valve-sparing root reimplantation was performed with decalcification of the cusps. Transthoracic echocardiography(TTE) at discharge revealed no aortic regurgitation, and peak velocity of BAV was 2.15 m/second, mean pressure gradient was 9.6 mmHg and aortic valve area was 2.15 cm2. TTE after 6 months revealed only slight elevation of the peak velocity to 2.78 m/second. To perform successful reimplantation in the case of BAV, anatomic orientation of the cusps should be approximately at 180° and the tissue of the cusps should either be normal or have only minor abnormalities. Valve-sparing root reimplantation for BAV needs a careful follow-up for progression of the aortic valve dysfunction.

[Valve-sparing Replacement in Patients with Aortic Root Dilatation].

Valve-sparing root replacement is increasingly used to overcome drawbacks associated with valvular prostheses. In our institution, 7 patients underwent valve-sparing root replacement from August 2016 to July 2017. The mean age was 45 years (range, 14~69 years). Three patients had Marfan syndrome and 1 had Loeys-Dietz syndrome with acute aortic dissection. All patients underwent surgery with reimplantation technique using a Valsalva graft. Two patients required repair of aortic valve leaflet prolapse. All patients had an excellent clinical course, with mild or no aortic regurgitation and a decrease in end-diastolic volume on echocardiography. These results support the continued use of valve-sparing root replacement in selected patients.

Long-Term Outcomes of Mitral Valve Repair for Active Endocarditis.

BACKGROUND: The long-term outcomes of mitral valve (MV) repair for active infective endocarditis (AE) are not well known, so the present study examined results from >5 years. METHODS AND RESULTS: We retrospectively reviewed 43 patients who underwent primary MV repair for AE at a single center between 1991 and 2009. Patients' mean age was 50.9 years, and 39% were female. The mean follow-up was 7.4 years, and 90.7% of the patients had serial echocardiographic studies over the years. We examined the data for mortality, mitral reoperation, and recurrent significant mitral regurgitation (MR). There were no early deaths but 6 late deaths. Survival was 92.6±4.1% for 5 years, and 83.5±7.3% for 10 years. The respective 5- and 10-year rates of freedom from MV reoperation were 90.5±4.5% and 86.6±5.8%, and for freedom from moderate or severe MR were 95.0±3.5 and 86.1±6.7%. Recurrence of endocarditis was observed in 2 patients (4.7%). Most (86%) of the survivors were in New York Heart Association class I. CONCLUSIONS: MV repair for AE is durable and offers acceptable long-term outcomes with low rates of recurrence and reoperation. (Circ J 2016; 80: 1148-1152).

Prolonged Antegrade Cerebral Perfusion via Right Axillary Artery (≥60 min) Does Not Affect Early Outcomes in a Repair of Type A Acute Aortic Dissection.

PURPOSE: We aim to investigate whether the duration of antegrade cerebral perfusion (ACP) via right axillary artery with an 8-mm prosthetic graft affects early outcomes in a repair of type A acute aortic dissection (AAD). METHODS: Over the 24 months from April 2010, a repair of AAD under ACP via the right axillary artery and mild hypothermic circulatory arrest (rectum temperature, 28-30°C) was performed in 34 patients. Mean age was 64.5 ± 13.7 years of age.Preoperative shock status was in three due to cardiac tamponade. Organ malperfusion occurred in 11 patients preoperatively. Mean follow-up period was 9.6 ± 8.4 months and follow-up rate was 100%. RESULTS: Hospital mortality rate was 8.8%. No newly required hemodialysis and new onset of temporary or permanent neurologic deficits were present in survivors.There were no statistically significant differences of mortality rate, new onset of permanent or temporary neurologic deficits and distal organ dysfunction between ACP duration <60 min and ≥60 min. The 12-month survival was 84.4% ± 6.4%. And, freedom from aorta-related events at 12 and 18 months were 100% ± 0.0% and 88.9% ± 10.5%, respectively. CONCLUSIONS: The duration of ACP via right axillary artery does not affect early outcomes following a repair of AAD.

Long-term outcomes of mitral valve repair with the Duran flexible ring.

BACKGROUND: Mitral annuloplasty is a reliable mitral valve repair technique. There are two types of annuloplasy rings: the rigid ring and the flexible ring. This study sought to examine the long-term results of mitral valve repair using a Duran flexible ring. METHODS: We retrospectively reviewed 226 patients who underwent primary mitral valve repair using the Duran flexible ring for mitral regurgitation between September 1994 and March 2003. Patients' mean age was 56.7 years, and 39% were female. The mean follow-up was 10.6 years (0.04 ∼ 18.3), and echocardiographic follow-up was 83.3% complete. RESULTS: There were three early and 25 late deaths. Survival was 89.3 ± 2.2 for 10 years, and 83.5 ± 3.2% for 15 years. The 10- and 15-year freedom from reoperation on the mitral valve were 96.4 ± 1.4 and 95.3 ± 1.7%, respectively. The 10- and 15-year freedom from moderate or severe mitral regurgitation were 92.5 ± 2.2 and 73.7 ± 7.1%, respectively. Cox regression analysis revealed that age, male gender, and isolated anterior leaflet prolapse were predictive of recurrent moderate or severe mitral regurgitation. CONCLUSIONS: Mitral valve repair for mitral regurgitation using a flexible Duran ring is safe and durable for more than 10 years.

Pulmonary Valvuloplasty by Autologous Pericardium in a Patient with Active Infectious Endocarditis and Osler's Disease.

Osler's disease is a rare condition of autosomal dominant inheritance characterized by bleeding and telangiectasia of the skin and mucosal membranes. A few reports exist of open-heart surgery in patients with Osler's disease. Here, the case is presented of a successful pulmonary valvuloplasty using autologous pericardium to treat active infectious endocarditis of the pulmonary valve in a patient with Osler's disease. Such patients are at higher risk of bacteremia because of their chronic nasal bleeding or pulmonary arteriovenous fistula. In patients with Osler's disease, valuvloplasty using autologous pericardium is considered effective for preventing the later recurrence of IE.

The impact of preoperative and postoperative pulmonary hypertension on long-term surgical outcome after mitral valve repair for degenerative mitral regurgitation.

PURPOSE: The aim of this study is to elucidate the impact of preoperative and postoperative pulmonary hypertension (PH) on long-term clinical outcomes after mitral valve repair for degenerative mitral regurgitation. METHODS: A total of 654 patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2010 were retrospectively reviewed. Patients were divided into PH(+) group (137 patients) and PH(-) group (517 patients). Follow-up was complete in 99.0%. The median follow-up duration was 7.5 years. RESULTS: Patients in PH(+) group were older, more symptomatic and had higher tricuspid regurgitation grade. Thirty-day mortality was not different between 2 groups (p = 0.975). Long-term survival rate was lower in PH(+) group; 10-year survival rate after the operation was 85.2% ± 4.0% in PH(+) group and 89.7% ± 1.8% in PH(-) group (Log-rank, p = 0.019). The incidence of late cardiac events were not different between groups, however, the recurrence of PH was more frequent in PH(+) group. The recurrence of PH had an adverse impact on survival rate, late cardiac events and symptoms. Univariate analysis showed age and preoperative tricuspid regurgitation grade were the predictors of PH recurrence. CONCLUSION: Early surgical indication should be advocated for degenerative mitral regurgitation before the progression of pulmonary hypertension and tricuspid regurgitation.

Long-term outcomes after mitral valve repair for degenerative mitral regurgitation with persistent atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) adversely affects surgical outcomes of mitral valve surgery. However, the long-term impact of Maze procedure has not been clear yet. PATIENTS AND METHODS: We retrospectively investigated 159 patients who underwent mitral valve repair for degenerative mitral regurgitation with persistent AF between 1991 and 2010. The mean age of patients was 63.1 ± 10.5 years. After we started performing Maze procedure in 2002, 65 patients underwent concomitant Maze procedure. The median follow-up time was 7.5 years. RESULTS: There was one operative death (0.63%). The overall survival rate was 91.0 ± 2.6% at 5 years and 79.1 ± 4.7% at 10 years. Survival was significantly better in patients who underwent Maze procedure than those who did not. The rate of freedom from AF in patients who underwent Maze procedure was 86.4 ± 4.5% at 1 year and 81.1 ± 5.6% at 5 years. The freedom rate from stroke was higher in patients who underwent Maze procedure than those who did not. Patients with postoperative AF had larger left ventricular systolic and diastolic diameters at follow-up and higher New York Heart Association functional class than patients without postoperative AF (1.4 ± 0.5 vs. 1.1 ± 0.3, p < 0.001). CONCLUSION: Maze procedure can have a positive effect on long-term survival, freedom from stroke, and cardiac function.

Efficacy of Stentless Aortic Bioprosthesis Implantation for Aortic Stenosis with Small Aortic Annulus.

BACKGROUND: In patients with small aortic annulus, sufficient size of stented aortic bioprosthesis cannot be implanted without additional procedures. In such cases, we use stentless aortic bioprosthesis to obtain sufficient effective orifice area. In this study, we investigated long-term impact of stentless aortic bioprosthesis on clinical outcomes, compared with stented aortic bioprosthesis. MATERIALS AND METHODS: We retrospectively investigated 140 patients who underwent aortic valve replacement (AVR) with porcine bioprosthesis for severe aortic stenosis between 1999 and 2010. Patients who had moderate or more aortic regurgitation and who underwent concomitant mitral procedures were excluded. A total of 69 patients (49%) were implanted stentless bioprosthesis (Freestyle group; Medtronic Inc, Minneapolis, Minnesota, United States) and 71 patients (51%) were implanted stented bioprosthesis (Mosaic group; Medtronic Inc). Follow-up was complete in 97.9% patients. Median follow-up period was 4.2 years. RESULTS: Patients in Freestyle group had smaller body surface area, smaller aortic annulus diameter, smaller aortic valve area, larger mean pressure gradient, higher peak velocity across aortic valve, larger left ventricular mass index (LVMI), and lower left ventricular ejection fraction (LVEF). Mean size of implanted prosthesis was larger in Freestyle group. In-hospital mortality was 1.4% in Freestyle group and 2.8% in Mosaic group (p = 0.980). Five-year survival rate was not different between two groups (5-year survival rate was 87.5 ± 4.7% in Freestyle group and 84.1 ± 7.5% in Mosaic group; log rank, p = 0.619). Late New York Heart Association functional class was lower in Freestyle group. Late LVMI and LVEF became similar between two groups. CONCLUSION: Stentless aortic bioprosthesis is superior in left ventricular remodeling after AVR for aortic stenosis and is especially effective for small aortic annulus.