Self-expandable transcatheter valve is a potentially useful option for a failing small surgical aortic bioprosthetic valve.

OBJECTIVE: Trans-catheter aortic valve implantation inside a failing surgical aortic valve bio-prosthesis has become an alternative for patients at high risk for redo surgical aortic valve replacement. However, the correlation between the size of the failing surgical aortic valve and the occurrence of prosthesis-patient mismatch after trans-catheter implantation is still controversial. The aim of this study is to analyze and report the results in Japanese patients. METHODS: Thirty patients who underwent trans-catheter aortic valve implantation inside a failing surgical aortic valve at our hospital were retrospectively reviewed with results from echocardiography and computed tomography. RESULTS: The patients' mean age was 84.5 ± 4.8 years. The mean body surface area was 1.42 ± 0.13 m2. The cohort was divided into two groups according to the size of the failing bio-prosthesis: small (≦19 mm) and large (> 19 mm). There were no significant differences in mean pressure gradient (12.2 ± 4.0 mmHg vs. 11.1 ± 1.2 mmHg; p = 0.54) and effective orifice area index (1.00 ± 0.26 cm2/m2 vs. 0.99 ± 0.25 cm2/m2; p = 0.92) between the groups at 6 months after trans-catheter implantation. The incidence of moderate (38.5% vs. 28.6%; p = 0.59) and severe (0% vs. 7.1%; p = 0.33) prosthesis-patient mismatch was equivalent. There was no significant difference in survival between the two groups (log-rank test p-value = 0.08). CONCLUSIONS: Trans-catheter implantation inside a failing small aortic valve did not increase the frequency of prosthesis-patient mismatch in this Japanese cohort.

Mitral valve early systolic billowing induces following annular expansion and leaflet augmentation in Barlow's disease: sequential analysis using 3D echocardiography.

AIMS: Although systolic expansion of the annulus has been recognized in Barlow's disease, the mechanisms of the unique pathological movement of the annulus and its relation to the leaflet augmentation have not yet been clarified. We aimed to investigate the detailed mechanisms of the characteristic mitral apparatus dynamics in Barlow's disease by frame-by-frame sequential geometric analysis using real-time 3D transoesophageal echocardiography. METHODS AND RESULTS: Fifty-three patients with Barlow's disease and severe mitral regurgitation without torn chordae, as well as 10 controls, were included. We evaluated geometric changes in the mitral complex using 3D transoesophageal echocardiography at five points during systole. To identify early systolic billowing of leaflets, the annulo-leaflet angle was measured. We also performed a more detailed analysis in four consecutive frames just before and after leaflet free-edge prolapse above the annulus plane. The median annulo-leaflet angle of both leaflets in early systole was >0° (above annulus plane) in patients with Barlow's disease, and billowing of the leaflet body was observed from early systole. The prolapse volume of both leaflets increased markedly from early to mid-systole [1.60 (0.85-2.80) to 4.00 (2.10-6.45) mL; analysis of variance (ANOVA), P < 0.001; post hoc, P < 0.05]. With frame-by-frame analysis, dynamic augmentation of the annulus and leaflets developed between frames just before and just after leaflet free-edge prolapse (ANOVA, P < 0.01; post hoc, P < 0.05). CONCLUSION: In Barlow's disease, early systolic billowing of the mitral leaflet induces systolic annulus expansion followed by leaflet augmentation and leaflet free-edge prolapse.

Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy.

Objective: In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. Methods: We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. Results: The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. Conclusions: In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.

Midterm outcomes after surgical aortic valve replacement with the INSPIRIS RESILIA from a multicenter AVR registry.

BACKGROUND: There have been few reports on the mid- to long-term safety and efficacy validation of the INSPIRIS RESILIA aortic bioprosthesis (Edwards Lifesciences LLC, Irvine, CA, USA) in Japan. Herein, we report the mid-term results of surgical aortic valve replacement (AVR) for aortic stenosis using INSPIRIS and evaluate the hemodynamics compared to the CEP Magna series from the multicenter AVR registry (the ACTIVIST registry). METHODS: Of the 1967 patients who underwent surgical or transcatheter AVR from the ACTIVIST registry, 66 patients who underwent isolated surgical AVR with INSPIRIS by December 2020 were included in this study, and the early and mid-term results were evaluated. Hemodynamics were evaluated by comparing 272 patients undergoing isolated surgical AVR with the Magna group using propensity score matching. RESULTS: The mean age was 74.0 ±â€¯7.8 years, and 48.5 % were women. In-hospital mortality was 1.5 %, and the survival rates at 1- and 2-years were 95.2 % and 95.2 %, respectively. After propensity score matching, echocardiographic findings at discharge demonstrated that peak velocity and mean pressure gradient in the INSPIRIS group were comparable, while the effective orifice area in the INSPIRIS group was significantly larger than those in the Magna group (p = 0.048). A patient-prosthesis mismatch at discharge was significantly lower in the INSPIRIS group (11.8 %) than in the Magna group (36.4 %) (p = 0.004). CONCLUSIONS: Surgical AVR with INSPIRIS was performed safely and the mid-term results were satisfactory. The hemodynamics of INSPIRIS were comparable to those of Magna.

Preceding Aortic Bare Stenting for Visceral and Limb Malperfusion before Proximal Surgical Repair of Stanford Type A Aortic Dissection.

Mesenteric malperfusion is a fatal complication of acute aortic dissection, which should rapidly be repaired. However, the optimal treatment strategy remains controversial in patients with type A aortic dissection. We report on a case with aortic bare stenting for visceral and lower limb malperfusion prior to the proximal repair. The visceral and limb reperfusion was obtained after aortic bare stenting and proximal repair was successfully performed. This technique can be an alternative option for visceral malperfusion due to type A aortic dissection. However, careful patient selection is required considering the risk of new dissection and rupture.

Mid-Term Outcomes of Late Open Conversion with Endograft Preservation for Sac Enlargement after Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: Late open conversion has sometimes been required for sac enlargement after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. Though the open repair with endograft preservation is considered less invasive compared to endograft removal, the mid-term outcomes are still unclear. The aim of this study is to evaluate the mid-term outcomes of late open conversion with endograft preservation after EVAR. METHODS: We reviewed patients who underwent late open conversion with endograft preservation for sac enlargement or rupture in our institution from May 2007 to December 2020. The open repair mainly consisted of ligation of lumber arteries or the median sacral artery and sacotomy. We additionally performed wrapping of plicated aneurysm with equine pericardium as much as possible. Patients were followed-up by a computed tomography scan and duplex ultrasound 1 and 6 months postoperatively, and each year thereafter. RESULTS: Of the 1,087 patients who underwent EVAR, 23 patients with a mean age of 81.5 years were included in this study. The mean duration post-EVAR was 35.6 months. Sac wrapping with equine pericardium was performed in 14 patients (60.9%). We additionally performed wrapping of the endograft junction by a Dacron knitted fabric in 1 case with type III endoleak and aortic neck banding in 4 cases with type I endoleak. The 30-day mortality was 0% and the rate of major complications was 4%. All-cause mortality was 21.7% which included 1 aneurysm-related death during a mean follow-up of 38.5 months. Sac re-enlargement was observed in 4 patients without the wrapping method. At 3 years, the aneurysmal diameter in the nonwrapping group significantly increased, compared with the wrapping group (P = 0.011). CONCLUSIONS: Late open conversion with endograft preservation is a feasible treatment; however, at times re-enlargement of the sac aneurysm occurs. The wrapping method has the potential to prevent sac re-enlargement after open conversion.

Clinically Optimal Neuropsychological Tests for Postoperative Cognitive Dysfunction in Heart Valve Surgeries.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is widely recognized and reported, but the lack of a uniform definition makes it difficult to evaluate its clinical impact. The aim of this study is to establish the optimal neuropsychological tests and definition of POCD relevant to clinical outcomes in heart valve surgeries.Methods and Results: Between June 2015 and December 2019, 315 patients undergoing elective heart valve surgeries (age ≥65 years) were enrolled. The Mini-Mental Status Examination, Montreal Cognitive Assessment (MoCA), and the Trail Making Test A and B were performed to evaluate cognitive function. Clinical endpoints were defined as readmission and death. The postoperative readmission and death rate were 17% and 3% (54/315 and 8/315; follow-up 266-1,889 days). By multivariable Cox hazard analysis, Short Physical Performance Battery (adjusted hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.49-0.98, P=0.001), MoCA change rate (adjusted HR: 0.64, 95% CI: 0.01-1.22, P=0.024), and intensive care unit stay (adjusted HR: 0.55%, 95% CI: 0.99-1.12, P=0.054) were detected as independent risk factors for combined events. The cutoff value was -12% in the change rate of MoCA. CONCLUSIONS: MoCA was the only neuropsychological test that predicted the clinical impact on complex events and has the potential to define POCD.

Predictive factors of distal stent graft-induced new entry after frozen elephant trunk procedure for aortic dissection.

OBJECTIVES: The incidence rate of distal stent graft-induced new entry (d-SINE) after frozen elephant trunk technique for aortic dissection remains controversial. The aim of this study was to investigate the incidence and seek the clinical and anatomical predictive factors. METHODS: This study is a retrospective multicentre evaluation of complications including d-SINE, aortic events and reintervention after the frozen elephant trunk procedure for aortic dissection. RESULTS: Our cohort included a total of 177 consecutive patients who underwent the frozen elephant trunk procedure for acute and chronic aortic dissection at 5 centres in Japan from May 2014 to March 2021. The incidence rate of d-SINE was 14.1% (25/177 patients). The cumulative incidence of d-SINE was 7.1%, 12.4% and 21.4% after 12, 36 and 60 months, respectively. d-SINE was not associated with mid-term survival rate. After competing risk regression analysis, onset time >48 h (subdistribution hazard ratio, 3.80; 95% confidence interval, 1.13-12.79; P = 0.031) was detected as an independent predictor. CONCLUSIONS: Awareness that there is a relatively higher incidence of d-SINE after frozen elephant trunk procedures is important. Non-hyper-acute phase was detected as an independent risk factor. Pre-emptive endovascular repair may be appropriate to protect new entry in high-risk patients.

Flow adjusted transmitral pressure gradient as a modified indicator of functional mitral stenosis after repair for degenerative mitral regurgitation.

BACKGROUND AND AIM: After repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes. METHODS: Three hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV. RESULTS: Common mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients' age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038-0.068] vs. 0.041 mmHg/ml, [0.031-0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = -0.37, p < .001). CONCLUSIONS: Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.

Clinical Impact of Flow Adjusted Transmitral Pressure Gradient After Surgical Annuloplasty for Functional Mitral Regurgitation.

Downsizing of mitral annulus due to mitral annuloplasty for ischemic functional mitral regurgitation (FMR) raises a new issue, functional mitral stenosis (FMS), defined as a decline of mitral hemodynamics. However, common mitral hemodynamic parameters are influenced by transmitral flow, therefore, the clinical impacts are still controversial. The aim of this study is to seek mitral hemodynamic indices (including transmitlra pressure gradient [TMPG] adjusted by left ventricular stroke volume [LVSV]) relevant to the mid-term outcomes after annuloplasty for ischemic functional mitral regurgitation (FMR). This study is a retrospective evaluation of mitral valve hemodynamic status by resting echocardiogram at several weeks after surgery. Eighty-one patients underwent mitral annuloplasty for ischemic FMR between September 2012 and June 2019. Postoperative adverse events occurred in 28 patients (34.6%), and the overall 5-year freedom from adverse events rate was 55.9%. Common mitral hemodynamic parameters were not associated with adverse events, but flow adjusted TMPG can be a correlative factor. By multivariable analysis, postoperative systolic pulmonary artery pressure and peak TMPG/LVSV were detected as independent predictors (adjusted hazard ratio 1.07 and 1.08, P < 0.001 and < 0.001). Additionally, risk stratification by peak TMPG (cut-off: 10 mm Hg) and LVSV (cut-off: 35 mL/m2) reflected the mid-term outcomes, perceptively (P = 0.007). Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after annuloplasty for ischemic FMR. However, flow adjusted TMPG was identfied as an independent predictor, and risk stratification by peak TMPG and LVSV reflected the mid-term outcomes, perceptively.

A case report of unexpected right-to-left shunt under mechanical support for post-infarction ventricular septal defect: evaluation with haemodynamic simulator.

BACKGROUND: Post-myocardial infarction ventricular septal defect (PIVSD) is a complication of acute myocardial infarction with high mortality. A percutaneous left ventricular assist device, Impella, is currently used in maintaining haemodynamic stability in PIVSD. CASE SUMMARY: A 65-year-old man was transferred to our hospital for treatment of acute myocardial infarction of the proximal right coronary artery. Percutaneous intervention was performed but haemodynamic instability continued. At 10 days after onset, the patient was diagnosed with PIVSD by echocardiogram. To stabilize haemodynamics, we initiated venoarterial extracorporeal membrane oxygenation (ECMO). Three days after ECMO initiation, pulmonary congestion increased and an echocardiogram revealed closed aortic valve and spontaneous echo contrast at the aortic root. After an Impella 2.5 was inserted for unloading of the left ventricle, the oxygenation level and cardiac function rapidly declined. Unexpectedly, an echocardiogram showed a right-to-left shunt (to-and-fro pattern) via PIVSD. By increasing the ECMO and decreasing Impella flow, the shunt flow changed to left-to-right, and oxygenation level and cardiac function improved. Ten days after ECMO was started, elective surgical repair was successfully performed. CONCLUSION: ECPELLA (ECMO + Impella) can offset the adverse effects of isolated ECMO support and reduce the PIVSD shunt flow. However, the risk of right-to-left shunt has not been reported, and ECPELLA caused a right-to-left shunt with deoxygenated systemic perfusion in the present case. A simulation study indicated that the right ventricular failure in PIVSD may pose a risk for right-to-left PIVSD shunt under Impella support.

Isolated endovascular repair of anomalous systemic arterial supply to the left basal lung.

Anomalous systemic arterial supply to the left basal lung is a rare congenital lung malformation, and its optimal treatment strategy is not well defined. We present a case of a 61-year-old man who underwent thoracic endovascular aortic repair (TEVAR) for anomalous systemic arterial supply to the left basal lung complicated with aneurysmal dilatation of the aberrant feeding artery. Computed tomography angiography after TEVAR revealed significant shrinkage of the aneurysmal portion as well as complete occlusion of the aberrant feeding artery. TEVAR proved to be a safe and efficient treatment for this rare arterial abnormality.

Primary Minimally Invasive Repair with Atriopericardial Anastomosis Technique for Pulmonary Vein Stenosis after Catheter Ablation.

A pulmonary vein (PV) stenosis is a rare adverse event associated with catheter ablation for atrial fibrillation, which can potentially impair quality of life. Although percutaneous PV angioplasty is performed as the initial treatment of choice, the incidence of restenosis is reported to be considerably high. Herein, we describe a successful case of severe PV stenosis treated by primary surgical repair using the atriopericardial anastomosis technique via right minithoracotomy.

Detrimental effects of elevated transpulmonary gradient on outcomes following restrictive mitral annuloplasty in patients with pre-existing pulmonary hypertension.

BACKGROUND: This study retrospectively examined the association between elevated trans-pulmonary gradient (TPG), which reflects pre-capillary contribution to pulmonary hypertension (PH), and postoperative pulmonary hemodynamics and outcomes following restrictive mitral annuloplasty (RMA) in patients with pre-existing PH. METHODS: Pre- and postoperative (1 month) cardiac catheterization was performed in 64 patients with severely impaired left ventricular function (i.e., ejection fraction ≤40%) and pre-existing PH (mean pulmonary artery pressure (PAP) ≥25 mmHg) who underwent RMA. Patients were segregated into two groups: low TPG (≤12 mmHg) and elevated TPG (>12 mmHg). The mean follow-up period was 54±27 months. The primary outcome seen was a change in pulmonary hemodynamics after RMA; secondary outcomes were composite adverse events, including all-cause mortality and readmission for heart failure. RESULTS: Compared to the low TPG group, patients in the elevated TPG group were more likely to show a postoperative mean PAP of ≥25 mmHg (84% vs. 38%), TPG of >12 mmHg (79% vs. 11%), and pulmonary vascular resistance of ≥240 dynes/sec/cm-5 (84% vs. 6.7%) (all P<0.001), although both groups showed comparable degrees of mitral regurgitation improvement. Serial echocardiography demonstrated that Doppler-derived systolic PAP, which once decreased in both groups, remained stable in the low group while steadily increasing in the elevated group (group effect P<0.001). Patients with elevated TPG had lower freedom from composite adverse events (5-year, 20% vs. 70%, P=0.003). After adjusting for baseline covariates, the elevated TPG was independently associated with increased risk of adverse events (adjusted hazard ratio 2.9, 95% CI: 1.2-6.9, P=0.017). CONCLUSIONS: Elevated TPG negatively affects postoperative pulmonary hemodynamics and late outcomes in patients with advanced cardiomyopathy and pre-existing PH who have undergone RMA. These findings suggest that the assessment of TPG should be included in post-RMA risk stratification.

Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes.

BACKGROUND: In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024). CONCLUSIONS: NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.