Successful laparoscopic arterial ligation of splenic artery aneurysm with a splenomesenteric trunk: a case report and literature review.

BACKGROUND: The mortality rate of splenic artery aneurysm rupture is very high, and patients with aneurysms larger than 30 mm are recommended for treatment, regardless of the presence or absence of symptoms. We herein report a case of splenic artery aneurysm with an abnormal bifurcation that was treated with laparoscopic ligation of the splenic artery. CASE PRESENTATION: A 51 year-old Japanese male was referred to our hospital because a splenic artery aneurysm was noted on abdominal echocardiography during a medical examination. The splenic artery bifurcated from the superior mesenteric artery (SMA), and a 38-mm splenic artery aneurysm was found just after the bifurcation; thus, surgery was performed. Intraoperative angiography was performed, a balloon catheter was placed before the splenic artery bifurcation, and laparoscopic splenic artery ligation was performed to prepare for sudden bleeding. After ligation of the splenic artery, angiography was performed again to confirm the absence of the splenic artery aneurysm and that the peripheral splenic artery was visible through the peripheral collateral vessels. The patient was discharged on the fourth postoperative day, with good progress. Contrast-enhanced computed tomography performed 1 month postoperatively confirmed the disappearance of the splenic artery aneurysm, and the contrast-enhanced peripheral splenic artery was visible. CONCLUSION: This is the first report of a safe laparoscopic artery ligation procedure for a splenic artery aneurysm with an abnormal splenic artery bifurcation from the SMA, in which a balloon catheter was placed at the splenic artery bifurcation.

Surgical Management of Giant Unruptured Left Sinus of Valsalva Aneurysm With Severe Aortic Regurgitation.

Left sinus of Valsalva aneurysms are extremely rare. Concomitant aortic valve regurgitation is a comorbidity in this pathology. This case report summarizes successful surgical treatment with aortic root replacement with a modified Bentall procedure in a 49-year-old female patient who had an unruptured huge left sinus of Valsalva aneurysm with severe aortic valve regurgitation. The intraoperative assessment showed severe adhesion between the left main trunk of the coronary artery and the left sinus of Valsalva aneurysm, and meticulous adhesion detachment was required.

Successful Medical Treatment for Aortoesophageal Fistula after Thoracic Endovascular Aortic Repair.

Aortoesophageal fistula is a fatal disease that requires surgical treatment. Due to the patient's wishes, we chose medical treatment for aortoesophageal fistula after thoracic endovascular aortic repair for a pseudoaneurysm in the distal anastomotic site after total aortic arch replacement. Satisfactory early and long-term outcomes were obtained with complete fasting and appropriate antibiotics.

Posterior mitral leaflet augmentation with autologous pericardial patch for the surgical treatment of severe atrial functional mitral regurgitation.

Atrial functional mitral regurgitation (MR) in patients with chronic atrial fibrillation has not been thoroughly discussed. Although there is insufficient evidence to surgically treat atrial functional MR, it is considered to be reasonable for those patients with severe atrial functional MR who have symptoms of heart failure despite adequate medical therapy. Herein, we report a useful technique for mitral valve repair using posterior mitral leaflet (PML) augmentation with autologous pericardium to obtain good mitral valve coaptation and eliminate atrial functional MR, including tethered PML, in a nonelderly patient.

Acute Limb Ischemia Caused by Embolus of Primary Lung Cancer Complicating Trousseau's Syndrome.

Limb ischemia caused by tumor embolus is rare. In this study, we report the case of a 77-year-old woman who suffered from acute ischemic limb. Computed tomography showed a tumor in the right bronchus invading the left atrium. The tumor fragments scattered resulting in the occlusion of the right iliac artery. The excluded embolus was revealed as a squamous cell carcinoma. Regarding the popliteal venous thrombus, Trousseau's syndrome was complicated. The patient was discharged without any complications. We believe that advanced lung cancer is a differential diagnosis of acute ischemic limbs and that successful limb rescue contributed to a patient's quality of life.

Endovascular Repair for Abdominal Aneurysm with Concomitant Aortoiliac Vein Fistula Diagnosed by Four-Dimensional Computed Tomography.

A 78-year-old man complaining of left leg swelling was diagnosed with an abdominal aortic aneurysm with an irregular margin. A four-dimensional computed tomography (CT) showed an aortoiliac vein fistula. An AFX stent graft was urgently implanted, and a Viabahn VBX was inserted into the left iliac vein. The aneurysmal sac was embolized. After the procedure, enhanced CT confirmed a patent stent graft without any endoleak or fistula. The patient was discharged ambulatory. An aortoiliac vein fistula is a differential diagnosis for leg edema, and a four-dimensional CT is beneficial in diagnosing the condition.

Reconstruction for rupture of profunda femoris artery aneurysm in a patient with sarcopenia.

Profunda femoris artery aneurysm (PFAA) is rare and has a high incidence of rupture. Herein, we report the case of an 80-year-old man who developed sarcopenia after gastric surgery. The patient presented to our hospital with a reddish thigh and was diagnosed with PFAA rupture. We performed aneurysmectomy and graft interposition in emergency. Postoperative enhanced computed tomography revealed an interposed graft, and the patient was discharged on postoperative Day 7. We considered that the PFAA patients with sarcopenia has a high risk of rupture because the muscles surrounding the profunda femoris artery became weak, and should be followed-up closely.

Inhibition of hepatocyte growth factor/c-Met signalling abrogates joint destruction by suppressing monocyte migration in rheumatoid arthritis.

OBJECTIVES: To determine the expression of hepatocyte growth factor (HGF) in RA biological fluids, the role of HGF in monocyte migration and the therapeutic effect of the c-Met inhibitor savolitinib in an arthritis model mice. METHODS: HGF/c-Met expression in serum, SF and synovial tissues (STs) obtained from RA patients and controls, as well as RA fibroblast-like synoviocytes (FLSs), was evaluated by ELISA and immunostaining. To determine the function of HGF in RA SF, we preincubated RA SF with a neutralizing anti-HGF antibody and measured the chemotactic ability of a human acute monocytic leukaemia cell line (THP-1). Additionally, examinations were conducted of SKG mice treated with savolitinib for 4 weeks. RESULTS: HGF levels in serum from RA patients were significantly higher than those in the controls and were decreased by drug treatment for 24 weeks. Additionally, the HGF level in SF from RA patients was higher than that in SF from OA patients. HGF and c-Met expression was also noted in RA STs. Stimulation of RA FLSs with TNF-α increased HGF/c-Met expression in a concentration-dependent manner, and c-Met signal inhibition suppressed production of fractalkine/CX3CL1 and macrophage inflammatory protein-1α/CCL3. When HGF was removed by immunoprecipitation, migration of THP-1 in RA SF was suppressed. In SKG mice, savolitinib significantly suppressed ankle bone destruction on µCT, with an associated reduction in the number of tartrate-resistant acid phosphatase-positive osteoclasts. CONCLUSION: HGF produced by inflammation in synovium of RA patients activates monocyte migration to synovium and promotes bone destruction via a chemotactic effect and enhanced chemokine production.

Echocardiography-guided aortic cannulation by the Seldinger technique for type A dissection with cerebral malperfusion.

OBJECTIVE: The purpose of this study was to assess the efficacy of echocardiography-guided ascending aortic central cannulation using the Seldinger technique during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion. METHODS: Between April 2007 and December 2017, 208 patients with type A acute aortic dissection underwent echocardiography-guided ascending aortic central cannulation using the Seldinger technique. We analyzed 16 of these patients (7.7%; median age, 63 years; 8 men) with stroke due to cerebral malperfusion, including 10 in a comatose state (Glasgow Coma Scale ≤8) and 6 with hemiplegia (manual muscle test ≤1) on hospital arrival. The Modified Rankin Scale was used to evaluate activities of daily living. RESULTS: The median time from onset of symptoms to establishment of cardiopulmonary bypass was 327 (176-561) minutes. The median time from the start of surgery to establishment of cardiopulmonary bypass was 34 (30-44) minutes. The mortality rate was 6.3% (1/16). In patients with preoperative coma, the Glasgow Coma Scale improved significantly after surgery from 4.5 to 15 at 30 days (P < .001). In patients with preoperative hemiplegia, 4 showed improved motor function on the manual muscle test score at 90 days. In all patients, Modified Rankin Scale scores improved significantly from 5.0 preoperatively to 1.0 after follow-up (P < .001). CONCLUSIONS: Echocardiography-guided ascending aortic central cannulation using the Seldinger technique has potential as a rapid and reliable perfusion route during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion.

ADAM-17 is expressed on rheumatoid arthritis fibroblast-like synoviocytes and regulates proinflammatory mediator expression and monocyte adhesion.

BACKGROUND: To examine the expression of ADAM-17 in rheumatoid arthritis (RA) biological fluids and the role it plays in monocyte adhesion to RA fibroblast-like synoviocytes (FLSs). METHODS: ADAM-17 expression was measured by enzyme-linked immunosorbent assays (ELISAs) in serum from normal (NL) subjects, osteoarthritis (OA) patients, and RA patients. We also analyzed the correlation between ADAM-17 and disease activity score 28 (DAS28) in RA. To determine expression of ADAM-17 in RA synovial tissues (STs) and RA FLS, we performed immunofluorescence analyses. To determine the role of ADAM-17 in RA, we transfected RA FLSs with small interfering RNA (siRNA) against ADAM-17. THP-1 adhesion to ADAM-17 siRNA-transfected RA FLSs was measured. Finally, adhesion molecules on ADAM-17 siRNA-transfected RA FLSs were measured using cell surface ELISAs. RESULTS: ADAM-17 in RA serum was significantly higher than that in NL and OA serum and correlated with DAS28. ADAM-17 in RA synovial fluids was higher than that in OA synovial fluids. ADAM-17 was expressed on RA cells lining STs and RA FLSs. THP-1 adhesion to ADAM-17 siRNA-transfected RA FLSs was decreased compared with that to control siRNA-transfected RA FLSs. ICAM-1 on TNF-α-stimulated ADAM-17 siRNA-transfected RA FLSs was significantly decreased compared with that on control siRNA-transfected RA FLSs. CONCLUSIONS: These data indicate that ADAM-17 is expressed on RA STs and plays a role in RA inflammation by regulating monocyte adhesion to RA FLSs. ADAM-17 might be an important inflammatory mediator in inflammatory diseases such as RA.

Is the serum oxytocin level altered by treatment in rheumatoid arthritis patients complicated with depression?

OBJECTIVE: The objective of this study was to investigate the factors associated with depression, including serum oxytocin (OXT) levels, disease activity, activities of daily living (ADL), and quality of life (QOL), and their effects on rheumatoid arthritis (RA). METHODS: This study included 42 RA patients who received treatment with a biological agent. We measured the following variables before and after 6 months of treatment: baseline characteristics, including age, sex, disease duration, smoking, and body mass index (BMI); prednisolone and methotrexate dose; serum level of matrix metalloproteinase-3 (MMP-3); erythrocyte sedimentation rate (ESR); and C-reactive protein (CRP) level. The disease activity of RA was assessed using the Simplified Disease Activity Index (SDAI); depression was assessed using the Hamilton Depression Rating Scale (HAM-D); ADL was assessed using the Health Assessment Questionnaire; and QOL was assessed using the Short Form (SF)-36. Serum OXT levels were determined using enzyme-linked immunosorbent assay. RESULTS: The HAM-D score significantly correlated with the SDAI, and the mental component summary (MCS) score of SF-36. However, the serum OXT levels did not correlate with the HAM-D score. Regression analysis using the HAM-D score as the objective variable identified female sex, smoking, BMI, and all the three component scores of SF-36, but not serum OXT levels, as significant factors. Comparisons between before and after treatment showed that the HAM-D score improved from 5 to 1.5; however, the serum OXT levels did not change. CONCLUSION: The variables of female sex, smoking, BMI, and QOL correlated with depression complicated with RA. However, serum OXT levels did not correlate directly.

Correction to: ADAM-17 is expressed in the inflammatory myopathy and is involved with interstitial lung disease.

The original version of this article, unfortunately, contained errors. Figure citation, caption, image and updated sentence in the Result section are now presented correctly in this article.

ADAM-17 is expressed in the inflammatory myopathy and is involved with interstitial lung disease.

The "A disintegrin and metalloprotease" (ADAM) family is thought to play an important role in tissue destruction and inflammatory reactions. ADAM-17 was first described as the protease responsible for tumor necrosis factor (TNF)-α shedding. Here, we have shown the expression of ADAM-17 in inflammatory myopathy and demonstrated the role of inflammation in interstitial lung diseases (ILD). ADAM-17 in inflammatory myopathy serum [polymyositis (n = 26), dermatomyositis (n = 34), and clinically amyopathic dermatomyositis (n = 10)] and healthy control (n = 19) was measured using enzyme-linked immunosorbent assay. The relationship between ADAM-17 and clinical data was examined. Finally, we performed immunohistological analysis to investigate the expression of ADAM-17 on the muscles of the inflammatory myopathy patients. ADAM-17 in inflammatory myopathy was significantly higher than that in healthy control (mean ± SEM, 1048 ± 312 and 36 ± 18 pg/ml, respectively; p < 0.05). ADAM-17 in post-treatment with corticosteroid and/or immunosuppressant serum was significantly decreased compared with that in pre-treatment serum (1465 ± 562 and 1059 ± 503 pg/ml, respectively; p < 0.01). ADAM-17 was significantly positively correlated with fractalkine/CX3CL1 and CXCL16. In addition, ADAM-17 in inflammatory myopathy with ILD patients (n = 46) was significantly higher than that in non-ILD patients (n = 24) (1379 ± 454 and 413 ± 226 pg/ml, respectively; p < 0.05). We found the expression of ADAM-17 on muscle biopsy tissue. ADAM-17 is expressed in inflammatory myopathies especially ILD, suggesting that ADAM-17 plays a role in lung fibrosis. ADAM-17 may be a potential target in inflammatory myopathies with ILD.

The Relationship between the Serum Oxytocin Levels, Disease Activity, the ADLs and the QOL in Patients with Rheumatoid Arthritis.

Objective To investigate the factors associated with depression, including the serum oxytocin (OXT) levels, disease activity, activities of daily living (ADLs) and quality of life (QOL), and their effects on rheumatoid arthritis (RA). Methods This study included 42-RA-patients. We measured the following variables before and after 6 months of treatment with biological disease-modifying antirheumatic drugs (bDMARDs): the baseline characteristics (including age, sex, disease duration, smoking, and body mass index), the doses of prednisolone and methotrexate, the serum level of matrix metalloprotease-3, the erythrocyte sedimentation rate and the C-reactive protein level. The disease activity of RA was assessed using the Simplified Disease Activity Index (SDAI), depression was assessed using the Hamilton Depression Rating Scale (HAM-D), the ADLs were assessed using the Health Assessment Questionnaire disability index and the QOL was assessed using the Short Form (SF)-36. The serum OXT levels were determined using an enzyme-linked immunosorbent assay. Results The HAM-D score was significantly correlated with the SDAI, and the mental component summary score of the SF-36. However, the serum OXT levels were not correlated with the HAM-D score. The serum OXT levels before and after bDMARDs treatment did not differ to a statistically significant extent, regardless of the presence of depression. Although the differences in the serum levels of OXT were observed prior to the initiation of treatment, there was no gender difference after treatment. Conclusion Although RA complicated by depression may be related to the following high disease activity, a poor QOL and poor ADLs, the serum OXT levels were not directly correlated.

Clinical Characteristics of Rheumatoid Arthritis Patients Achieving Functional Remission after Six Months of Non-tumor Necrosis Factor Biological Disease-Modifying Antirheumatic Drugs (DMARDs) Treatment.

Objectives We aimed to identify the factors that predict the likelihood of remission based on a health assessment questionnaire (HAQ) in rheumatoid arthritis (RA) patients who received non-tumor necrosis factor (TNF) biologics for six months before they commenced definitive treatment. Methods The subjects consisted of 97 RA patients treated with tocilizumab or abatacept for 6 months. The following characteristics were investigated: age, gender, body mass index, steroid and methotrexate dosage, serum matrix metalloproteinase-3 levels, simplified disease activity index (SDAI) score, HAQ score (for assessing the activities of daily living [ADL]) and the short form (SF)-36 score (for assessing the quality of life [QOL]). Remission based on the HAQ score is defined as HAQ ≤0.5 after 6 months of treatment. The subjects were divided into two groups: patients with HAQ score ≤0.5 and HAQ score >0.5, and a retrospective study was conducted. Results The group of RA patients who entered remission based on the HAQ (53 patients) had a lower SDAI than the patients who did not enter remission (44 patients), and the RA patients had a lower tender joint count (TJC) and HAQ scores and a lower physician's global assessment (PGA) than those who did not enter remission. The physical component summary score (PCS) and role/social component summary score (RCS) of the SF-36 summary score were higher in the remission patients than in those without. Before the start of the treatment, the HAQ score, patients' global assessment (PtGA) and PCS and mental component summary score (MCS) of the SF-36 were determined based on a logistic regression analysis. Conclusion Our findings suggest that RA patients with lower HAQ scores and PtGA and higher PCS and MCS of the SF-36 at baseline are more likely to achieve HAQ remission with non-TNF biologic treatment than others.

Predictor of the Simplified Disease Activity Index 50 (SDAI 50) at Month 3 of bDMARD Treatment in Patients with Long-Established Rheumatoid Arthritis.

OBJECTIVES: The Simplified Disease Activity Index (SDAI) 50 has good agreement with European League Against Rheumatism (EULAR) response measures for early Rheumatoid Arthritis (RA). There have been reports on early RA, but not on long-established RA. In this study, we analysed the relationships between various baseline factors and SDAI 50 after three months of treatment with biological disease-modifying antirheumatic drugs (bDMARDs) to determine the prognostic factors for long-established RA. METHODS: Subjects were 260 RA patients who had been treated with bDMARDs for 3 months. The following characteristics were investigated: Patient backgrounds, the erythrocyte sedimentation rate (ESR), C-reactive protein and serum matrix metalloproteinase-3 levels, SDAI scores, and health assessment questionnaire disability index and short form-36 scores. As a primary outcome index, the SDAI response was defined as a 50% reduction in the SDAI score between baseline and 3 months (SDAI 50). RESULTS: Baseline values of disease duration (odds ratio: 0.942, 95% CI: 0.902-0.984), smoking history (odds ratio: 2.272, 1.064-4.850), 28-tender joint count (odds ratio: 0.899, 0.827-0.977), evaluator's global assessment (odds ratio: 1.029, 1.012-1.047) and ESR (odds ratio: 1.015, 1.001-1.030) were determined to be significant factors based on logistic regression analysis. CONCLUSION: Our study demonstrated that RA patients with shorter disease duration, no smoking, and higher RA disease activity are more likely to achieve SDAI 50 through bDMARD treatment.

The SYNTAX score is correlated with long-term outcomes of coronary artery bypass grafting for complex coronary artery lesions.

OBJECTIVES: We analysed retrospectively the long-term outcomes of conventional coronary artery bypass grafting (CABG) as employed routinely for complex coronary lesions by observing patients with low (0-22), intermediate (23-32) and high (≥33) SYNTAX scores. The purpose of this study was to evaluate the correlation between the SYNTAX score and long-term major adverse cardiac and cerebrovascular events (MACCEs) including all-cause death, stroke, myocardial infarction (MI) and repeat revascularization after CABG. METHODS: The study enrolled 396 consecutive patients with stable and untreated left main and/or three-vessel disease, who had been referred to our heart team from 2000 through 2009. They all routinely underwent conventional CABG. The three groups (low score; n = 159, intermediate score; n = 150, high score; n = 87) were compared, looking at the primary endpoint of MACCE and its components. We also analysed the effects of diverse variables on long-term MACCEs after the operation. RESULTS: The cumulative 10-year MACCE rates in patients with low, intermediate and high SYNTAX score were 25.3, 35.8 and 48.1%, respectively. The Kaplan-Meier cumulative event curves showed a significantly higher MACCE rate after CABG in patients with a higher SYNTAX score than in those with a lower score (log-rank P = 0.0012). This was mainly because of a significantly increased rate of repeat revascularization in the higher SYNTAX score group (log-rank P = 0.0032). The cumulative rate of repeat revascularization at 10 years in patients having low, intermediate and high SYNTAX score were, respectively, 4.6, 15.7 and 16.8%. The cumulative rates of the combined outcomes of death/stroke/MI at 10 years did not show statistical differences between the three groups (22.3% with low, 25.0% with intermediate and 38.4% with high score, log-rank P = 0.063). In the multivariable analysis, the SYNTAX score [hazard ratio (HR) 1.03, P = 0.0043] and logistic EuroSCORE II (HR 1.34, P = 0.0012) were found to be significant predictors of long-term MACCEs. CONCLUSIONS: The SYNTAX score is correlated with long-term outcomes, in terms of MACCEs, after conventional CABG for complex coronary lesions and is prognostic of long-term outcomes of CABG for patients with complex lesions.

Serum anticyclic citrullinated protein antibody titers are correlated with the response to biological agents in patients with rheumatoid arthritis.

Anticyclic citrullinated protein antibody (ACPA) is known as an important indicator for diagnosis of rheumatoid arthritis (RA). Our aim was to examine the relationship between the serum ACPA titer at baseline and responsiveness to biological agents (antagonists of either tumor necrosis factor or interleukin 6) in patients with RA. ACPA was measured using second-generation chemiluminescent enzyme immunoassay. Disease activity was assessed using disease activity scores 28. Fifty-seven RA patients with biological agents were enrolled, and the median ACPA titer at baseline was 110.0 U/mL. The median ACPA titer was 23.3 U/mL and 183.0 U/mL in the good and moderate response groups, respectively, which were significantly lower than in the no response group (404.0 U/mL). In addition, 69.2% and 26.9% of patients with low (<100 U/mL) and moderate (100-499 U/mL) basal ACPA titers showed a moderate to good response. Of the patients with higher (≥500 U/mL) basal ACPA titers, only 14.0% and 42.5% showed a good or moderate response, respectively. The remission rate was 77.8% in the ACPA-negative, which was significantly higher than the rate of 25% in the ACPA-positive patients. The results suggest that the ACPA titers are correlated with the efficacy of the biological agents used in patients with RA.

Long-term outcomes and risk analyses of coronary bypass for left main disease.

BACKGROUND: We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease. METHODS: From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation. RESULTS: The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003). CONCLUSIONS: With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.

Non-heart transplant surgical approaches with left ventricular restoration and mitral valve operation for advanced ischaemic cardiomyopathy.

OBJECTIVES: The aim of this study was to assess long-term outcomes of non-heart transplant surgical approaches to advanced ischaemic cardiomyopathy (ICM), including left ventricular restoration (LVR) and mitral valve operation. METHODS: Since September 2002, 102 consecutive patients (mean age 65, 18 females) with advanced ICM [ejection fraction (EF) <40%, left ventricular end-systolic volume index (LVESVI) > 60 ml/m(2)] were treated using non-heart transplant procedures. A total of 84 patients with asynergy of large scar exceeding 35% of left ventricular (LV) perimeter underwent LVR, and 30 patients with greater than or equal to moderate mitral regurgitation (MR) underwent mitral valve operation such as annuloplasty (n = 23) and valve replacement (n = 7). Patients were divided into four groups according to their interagency registry for mechanically assisted circulatory support (INTERMACS) profiles: Profile 1-2 (the highest levels of clinical compromise; n = 9), Profile 3-4 (n = 40), Profile 5-6 (n = 32) and Profile ≥ 7 (n = 21). We compared the four groups, looking at survival, major adverse cardiac and cerebrovascular event (MACCE), New York Heart Association (NYHA) status, LV volume and function. RESULTS: The overall 8-year survival including 3 hospital deaths (2.9%) was 64.3% without sudden death due to arrhythmia. Ninety-nine survivors showed significant improvement in the mean NYHA status, from 2.9 to 1.4, and the mean EF (33.2-41.7%) (P < 0.0001). The mean LVESVI was significantly reduced from 104.1 to 61.4 ml/m(2) (41% volume reduction) (P < 0.0001). Seven-year survival in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 50.0, 57.2, 60.3 and 95.2%, respectively (P = 0.13). Freedom from MACCE at 5 years in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 29.6, 47.0, 67.2 and 95.2%, respectively (P = 0.0067). The improvements in NYHA status were significantly greater in patients with higher levels of clinical compromise (P < 0.0001), although, there was no significant difference in LV volume reduction and functional improvement among the four groups. Patients with Profile ≥ 7 had significantly better survival at 7 years (hazard ratio (HR): 0.11, P = 0.046) and freedom from MACCE at 5 years (HR: 0.053, P = 0.0066) compared with patients with Profiles 1-2. CONCLUSIONS: Our non-heart transplant surgical approaches using LVR and mitral valve operation for advanced ICM yielded excellent long-term outcomes in terms of survival and NYHA status, even in patients who are potential candidates for heart transplantation or LV assist devices; and are encouraging in a very particular situation where heart transplantation is limited due to organ storage.