Apixaban use in an atrial fibrillation patient with double mechanical heart valves: a case report.

BACKGROUND: Warfarin is the only approved oral anticoagulant for long-term prophylaxis against valve thrombosis and thromboembolism in patients with mechanical heart valves. To date, apixaban for patients with double (aortic and mitral) mechanical heart valves has not been reported in the literature. CASE SUMMARY: We report the case of a 50-year-old female who underwent double (aortic and mitral) mechanical valve replacement in February 2017. Warfarin was prescribed after mechanical valve replacement. However, she complained of side effects of warfarin, including tingling sensation and numbness of legs, urticaria, skin rash, and nausea and voluntarily stopped taking medication. In December 2018, she was admitted to the emergency room due to ongoing chest pain. Coronary angiogram revealed embolic myocardial infarction at the left circumflex coronary artery. Nevertheless, she continued to refuse to take warfarin after anticoagulant therapy for coronary artery embolism. Given the patient's objection, we prescribed apixaban 5 mg b.i.d. since February 2019. When she was diagnosed with atrial fibrillation in April 2020, no intracardiac thrombosis was confirmed on computed tomography and electrical cardioversion was performed safely. While on apixaban, no evidence of prosthetic valve thrombosis or thrombo-embolic events was observed during a 24-month period. CONCLUSION: We report the efficacy and safety of apixaban in a patient with atrial fibrillation and double mechanical heart valves for preventing prosthetic valve thrombus and systemic embolism.

The Association between Morphological and Functional Characteristics of the Bicuspid Aortic Valve and Bicuspid Aortopathy.

OBJECTIVE: To identify the association between morphological and functional characteristics of the bicuspid aortic valve (BAV) and bicuspid aortopathy and to identify the determinants of aortic dilatation using transthoracic echocardiography (TTE) and cardiac computed tomography (CCT). MATERIALS AND METHODS: This study included 312 subjects (mean [SD] age, 52.7 [14.3] years; 227 males [72.8%]) who underwent TTE and CCT. The BAVs were classified by anterior-posterior (BAV-AP) or right-left (BAV-RL) orientation of the cusps and divided according to the presence (raphe+) or absence of a raphe (raphe-) based on the CCT and intraoperative findings. The dimensions of the sinus of Valsalva and the proximal ascending aorta were measured by CCT. We assessed the determinants of aortic root and proximal ascending aortic dilatation (size index > 2.1 cm/m²) by Univariable and multivariable logistic regression analyses. RESULTS: Of the 312 patients, BAV-AP was present in 188 patients (60.3%), and 185 patients (59.3%) were raphe+. Moderate-to-severe aortic stenosis (AS) was the most common hemodynamic abnormality (54.8%). The most common type of aortopathy was the combined dilated root and mid-ascending aortic phenotype (62.5%). On multivariable analysis, age and AS severity were significantly associated with aortic root dilatation (p < 0.05), and age, sex, and AS severity were significantly associated with ascending aortic dilatation (p < 005). However, the orientation of the cusps, presence of a raphe, and severity of aortic regurgitation were not associated with aortic root and ascending aortic dilatation. CONCLUSION: BAV morphological characteristics were not determinants of aortic dilatation. Age, sex, and AS severity were predictors of bicuspid aortopathy. Therefore, age, sex, and AS severity, rather than valve morphology, need to be considered when planning treatment for BAV patients.

The effects of endoplasmic reticulum stress on the expression of exosomes in ventilator-induced lung injury.

BACKGROUND: We hypothesized that endoplasmic reticulum stress (ER) would be associated with exosomes in ventilator-induced lung injury (VILI), and that inhibition of ER stress would be linked to less occurrence of VILI or less damage in VILI. METHODS: Mice were randomly allocated to a control group and an Inhibitor group. Normal saline (0.5 mL) was administered intraperitoneally to the control group and 4-phenylbutyric acid (4-PBA) (10 mg/kg mixed in normal saline 0.5 mL) to the inhibitor group. After mechanical ventilation to induce VILI for 2 hours, exosomes from bronchoalveolar lavage (BAL), protein kinase R-like endoplasmic reticulum (PERK), Toll-like receptor 4 (TLR4), and the injury score of the lung tissue were determined. RESULTS: The expression of cluster of differentiation (CD) 63, the marker for exosomes from BAL, was significantly lower (P=0.017) in the inhibitor group [0.967%±0.283% (0.870, 0.810-1.227)] than in the control group [1.559%±0.489% (1.355, 1.259-2.008)]. The expression of PERK and TLR4 from lung tissue was also significantly lower in the inhibitor group than in the control group. The injury score of lung tissue was lower in the inhibitor group than in the control group. CONCLUSIONS: The release of exosomes in mice with VILI was associated with ER stress. The inhibition of ER stress reduced the release of exosomes from the lung with less expression of PERK and TLR4 and reduced pulmonary damage in mice with VILI.

Ultrasonography-guided antegrade common femoral artery approach: Factors associated with access time.

INTRODUCTION: The aim of this study was to evaluate the feasibility and safety of ultrasonography-guided antegrade common femoral artery puncture and subsequent superficial femoral artery access without the aid of fluoroscopy. Factors that could affect access time were also assessed. METHODS: A total of 294 cases from 218 consecutive patients (163 men, 55 women; mean age: 66.9 ± 12.7 years) who underwent lower extremity endovascular procedures were retrospectively evaluated. The time between the injection of local anesthetic and the insertion of the microsheath into the superficial femoral artery was measured. The common femoral artery diameter, cutis thickness, distance between arterial puncture site and common femoral artery bifurcation, degree of common femoral artery calcification, body mass index, and history of previous access were investigated to assess their relationship with access time. Furthermore, all cases were assessed with ultrasonography for access-site complications before discharge. RESULTS: Technical success was achieved in 293 of 294 procedures (99.7%). The mean time for superficial femoral artery access was 1.9 ± 0.8 min (range, 0.7-3.7 min). Additional fluoroscopic guidance was needed in one case. There were moderately positive correlations of body mass index (r = 0.75; p < 0.001) and cutis thickness (r = 0.58; p < 0.001) with access time. The other variables failed to reveal significant correlations with access time. Five groin hematomas occurred after percutaneous transluminal angioplasty. Complications such as pseudoaneurysm, arteriovenous fistula, or retroperitoneal hematoma were not observed. CONCLUSION: Antegrade common femoral artery puncture with subsequent superficial femoral artery access conducted solely under ultrasonography guidance was feasible and safe. In addition, the antegrade access time showed positive correlations with body mass index and cutis thickness.

Association between aortic valvular calcification and characteristics of the aortic valve in patients with bicuspid aortic valve stenosis.

BACKGROUND: Aortic valve calcification quantification using cardiac computed tomography (CCT) is a reliable marker for aortic stenosis (AS) in patients with bicuspid aortic valve (BAV) disease. PURPOSE: To determine the association of Agatston aortic valve calcium score (AVCS) with morphological and hemodynamic characteristics of BAV and define cut-off AVCS for optimizing the grade of AS in patients with bicuspid AS. MATERIAL AND METHODS: This study included 161 BAV patients with AS regardless of aortic regurgitation who underwent transthoracic echocardiography and CCT. BAVs were classified according to orientation of cusps and presence of raphe. Associations of AVCS with characteristics of BAV morphology and functional variables were determined by linear regression analysis. Area under the receiver operating characteristic curve (AUC) was used to determine the cut-off AVCS greater than which the diagnosis of severe AS was optimized. RESULTS: AVCS was significantly different according to sex ( P < 0.001), AS severity ( P < 0.001), type of valvular dysfunction ( P = 0.011), and orientation of cusps ( P = 0.028). Multiple linear regression showed that AVCS was significantly associated with sex (estimate = -0.583, P < 0.001) and AS severity (estimate = 0.817, P < 0.001). AVCS was a predictor for severe AS with AUC of 0.80 in both women ( P = 0.002) and men ( P < 0.001). Its cut-off value was 1423 Agatston unit (AU) in women and 2573 AU in men. CONCLUSIONS: In patients with bicuspid AS, AVCS was significantly higher in men and those with severe AS. However, AVCS was not significantly associated with morphological characteristics of BAV or the type of valvular dysfunction.

Comparison of the Diagnostic Accuracies of 1.5T and 3T Stress Myocardial Perfusion Cardiovascular Magnetic Resonance for Detecting Significant Coronary Artery Disease.

Objective: To compare the diagnostic performance of cardiovascular magnetic resonance (CMR) myocardial perfusion at 1.5- and 3-tesla (T) for detecting significant coronary artery disease (CAD), with invasive coronary angiography (ICA) as the reference method. Materials and Methods: We prospectively enrolled 281 patients (age 62.4 ± 8.3 years, 193 men) with suspected or known CAD who had undergone 1.5T or 3T CMR and ICA. Two independent radiologists interpreted perfusion defects. With ICA as the reference standard, the diagnostic performance of 1.5T and 3T CMR for identifying significant CAD (≥ 50% diameter reduction of the left main and ≥ 70% diameter reduction of other epicardial arteries) was determined. Results: No differences were observed in baseline characteristics or prevalence of CAD and old myocardial infarction (MI) using 1.5T (n = 135) or 3T (n = 146) systems. Sensitivity, specificity, positive and negative predictive values, and area under the receiver operating characteristic curve (AUC) for detecting significant CAD were similar between the 1.5T (84%, 64%, 74%, 76%, and 0.75 per patient and 68%, 83%, 66%, 84%, and 0.76 per vessel) and 3T (80%, 71%, 71%, 80%, and 0.76 per patient and 75%, 86%, 64%, 91%, and 0.81 per vessel) systems. In patients with multi-vessel CAD without old MI, the sensitivity, specificity, and AUC with 3T were greater than those with 1.5T on a per-vessel basis (71% vs. 36%, 92% vs. 69%, and 0.82 vs. 0.53, respectively). Conclusion: 3T CMR has similar diagnostic performance to 1.5T CMR in detecting significant CAD, except for higher diagnostic performance in patients with multi-vessel CAD without old MI.

Diagnostic performance of static single-scan stress perfusion cardiac computed tomography in detecting hemodynamically significant coronary artery stenosis: a comparison with combined invasive coronary angiography and cardiovascular magnetic resonance-myocardial perfusion imaging.

Background Non-invasive anatomical and physiological evaluations of coronary artery disease (CAD) may be obtained with static single-scan stress perfusion cardiac computed tomography (SSPCT). Purpose To determine the diagnostic performance of static SSPCT for identifying hemodynamically significant CAD. Material and Methods This prospective study included 29 patients with suspected or known CAD who underwent static SSPCT, cardiovascular magnetic resonance myocardial perfusion imaging (CMR-MPI), and invasive coronary angiography (ICA). CT was performed as follows: (i) coronary calcium scan; (ii) static SSPCT for both coronary artery (coronary CT angiography [CCTA]) and myocardial perfusion (perfusion CT [PCT]) during adenosine infusion; (iii) late-phase scan. The diagnostic performance of CCTA alone, PCT alone, and SSPCT for the detection of a hemodynamically significant CAD (a perfusion defect in a vascular territory subtended by a coronary vessel with ≥ 50% stenosis) was compared with that of combined ICA/CMR-MPI representing the standard of reference. Results Twenty-three (79%) patients and 47 (54%) vascular territories manifested ischemia-causing coronary stenoses by combined ICA/CMR-MPI. The per-vessel sensitivity, specificity, positive and negative predictive values, and area under the receiver operating characteristic curve (AUC) of the SSPCT were 92%, 88%, 90%, 90%, and 0.90, respectively, compared to those of the combined ICA/CMR-MPI. These values for the CCTA alone were 96%, 63%, 75%, 93%, and 0.79, respectively; and the values for the PCT alone were 94%, 83%, 86%, 92%, and 0.88, respectively. The AUC of SSPCT was significantly ( P = 0.013) higher than that of the CCTA alone. Conclusion Static SSPCT may facilitate detection of hemodynamically significant CAD.

Morphological and Functional Evaluation of Quadricuspid Aortic Valves Using Cardiac Computed Tomography.

OBJECTIVE: The aim of this study was to identify the morphological and functional characteristics of quadricuspid aortic valves (QAV) on cardiac computed tomography (CCT). MATERIALS AND METHODS: We retrospectively enrolled 11 patients with QAV. All patients underwent CCT and transthoracic echocardiography (TTE), and 7 patients underwent cardiovascular magnetic resonance (CMR). The presence and classification of QAV assessed by CCT was compared with that of TTE and intraoperative findings. The regurgitant orifice area (ROA) measured by CCT was compared with severity of aortic regurgitation (AR) by TTE and the regurgitant fraction (RF) by CMR. RESULTS: All of the patients had AR; 9 had pure AR, 1 had combined aortic stenosis and regurgitation, and 1 had combined subaortic stenosis and regurgitation. Two patients had a subaortic fibrotic membrane and 1 of them showed a subaortic stenosis. One QAV was misdiagnosed as tricuspid aortic valve on TTE. In accordance with the Hurwitz and Robert's classification, consensus was reached on the QAV classification between the CCT and TTE findings in 7 of 10 patients. The patients were classified as type A (n = 1), type B (n = 3), type C (n = 1), type D (n = 4), and type F (n = 2) on CCT. A very high correlation existed between ROA by CCT and RF by CMR (r = 0.99) but a good correlation existed between ROA by CCT and regurgitant severity by TTE (r = 0.62). CONCLUSION: Cardiac computed tomography provides comprehensive anatomical and functional information about the QAV.

Organizing Thrombus Mimicking a Cardiac Tumor Located at the Mitral-Aortic Intervalvular Fibrosa.

Thrombosis at the left ventricular outflow tract occurs without any detectable heart disease or predisposing factors only extremely rarely. A 48-year-old male visited Konkuk University Medical Center with loss of consciousness one month prior to presentation. Before he visited our hospital, he had been diagnosed with a cardiac tumor, which was located between the left atrium and posterior aortic root, and which was adjacent to both the aortic and mitral valves. Cardiac transplantation was recommended at the other hospital because of the high risk of cardiac dysfunction induced by both aortic and mitral valvular dysfunction after surgical resection. Based on preoperative transthoracic echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging, and intra-operative transesophageal echocardiography, we considered it to be a benign tumor. Complete resection was achieved and the pathology confirmed organizing thrombus. We report a case of organizing thrombus mimicking a cardiac tumor, which was located at the mitral-aortic intervalvular fibrosa of the left ventricular outflow tract without any heart disease.

Midterm results of mitral valve repair with lifting annuloplasty strip for acute phase infective endocarditis.

BACKGROUND: Mitral valve repair is favored over replacement due to superior outcomes. However, extensive infective endocarditis (IE) often has been considered unreconstructable. We retrospectively analyzed the mid-term outcomes of an individualized repair approach using a lifting annuloplasty strip. METHODS: Between December 2007 and March 2014, 27 consecutive patients with acute single mitral valve IE (age 43 ± 16 years, 11 men) underwent lifting mitral annuloplasty (LMA) with a strip (Mitracon® strip, 28 mm in 4, 32 mm in 10, and 34 mm in 13). Blood culture was positive in 70 % (Streptococcus 10, Staphylococcus 4, HACEK 3, Enterococcus 1, Gram negative bacilli 1). One case (4 %) had a previously repaired mitral valve-the repair was redone. Via right thoracotomy (74 %) or median sternotomy (26 %), repair was performed by removal of vegetation and resection of infected tissue, the defect typically then being repaired using a bovine pericardial patch (81 %). Artificial chordae were formed in 5 patients. Nine (33 %) of them had posterior leaflet augmentation (PLA) to get sufficient coaptation height. Clinical and echocardiographic follow-up were performed. RESULTS: Compared with preoperative ones, postoperative echocardiograms revealed decreases of left ventricular (LV) end-diastolic dimensions (57.2 ± 6.3 versus, 45.4 ± 6.2, or 44.8 ± 4.1 mm, all p < 0.01). The LV ejection fraction decreased immediately, but recovered (64.4 ± 9.6 % vs. 54.5 ± 9.8 %, or 65.2 ± 6.1 %, p = 0.002, p = 1.000, respectively). The latest follow-up echocardiograms (median 28 months) universally showed no or minimal regurgitation, with a preserved mitral valve opening area (2.27 ± 0.48 cm(2)). During the clinical follow-up (median, 54 months), one (3.7 %) death was observed (in-hospital, due to biliary sepsis and pneumonia). There was no reoperation or major cardiovascular event. The 5 year survival rate was 96.3 %. CONCLUSIONS: The repair technique of LMA and/or PLA in patients with IE achieved good structural and functional outcomes as well as an excellent 5 year survival rate. An individualized repair approach should be recommended in patients with acute phase IE.

Postoperative Outcomes of Mitral Valve Repair for Mitral Restenosis after Percutaneous Balloon Mitral Valvotomy.

BACKGROUND: There have been a number of studies on mitral valve replacement and repeated percutaneous mitral balloon valvotomy for mitral valve restenosis after percutaneous mitral balloon valvotomy. However, studies on mitral valve repair for these patients are rare. In this study, we analyzed postoperative outcomes of mitral valve repair for mitral valve restenosis after percutaneous mitral balloon valvotomy. METHODS: In this study, we assessed 15 patients (mean age, 47.7±9.7 years; 11 female and 4 male) who underwent mitral valve repair between August 2008 and March 2013 for symptomatic mitral valve restenosis after percutaneous mitral balloon valvotomy. The mean interval between the initial percutaneous mitral balloon valvotomy and the mitral valve repair was 13.5±7 years. The mean preoperative Wilkins score was 9.4±2.6. RESULTS: The mean mitral valve area obtained using planimetry increased from 1.16±0.16 cm(2) to 1.62±0.34 cm(2) (p=0.0001). The mean pressure half time obtained using Doppler ultrasound decreased from 202.4±58.6 ms to 152±50.2 ms (p=0.0001). The mean pressure gradient obtained using Doppler ultrasound decreased from 9.4±4.0 mmHg to 5.8±1.5 mmHg (p=0.0021). There were no early or late deaths. Thromboembolic events or infective endocarditis did not occur. Reoperations such as mitral valve repair or mitral valve replacement were not performed during the follow-up period (39±16 months). The 5-year event-free survival was 56.16% (95% confidence interval, 47.467-64.866). CONCLUSION: On the basis of these results, we could not conclude that mitral valve repair could be an alternative for patients with mitral valve restenosis after percutaneous balloon mitral valvotomy. However, some patients presented with results similar to those of mitral valve replacement. Further studies including more patients with long-term follow-up are necessary to determine the possibility of this application of mitral valve repair.

Lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair: midterm outcomes.

BACKGROUND: We evaluated the midterm outcomes of lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair. METHODS: Between October 2007 and December 2012, 341 consecutive patients with significant mitral regurgitation underwent lifting posterior mitral annuloplasty using a specially designed fabric annuloplasty strip that lifts the middle portion of the posterior annulus. Associated procedures for mitral valve repairs, such as patch valvuloplasty for posterior leaflet prolapse (n=80), new chord placement for anterior leaflet prolapse (n=33), commissurotomy (n=29), and posterior leaflet extension (n=23), were performed in 141 patients (41.3%). RESULTS: Thirty-day mortality was 0.9%. Nine late deaths (2.6%) occurred. Mean overall survival at 5 years was 96.0%±1.1%. During the mean follow-up period of 38±17 months, six patients (1.8%) underwent valve-related reoperation (5-year freedom from valve-related reoperation, 98.1%±0.8%). At 5 years, mean freedom from recurrence of mitral regurgitation grade 3+ to 4+ (moderate to severe) was 95.1%±1.6%. The mean valve pressure gradient (PG) was 3.2±1.5 mmHg across all strip sizes at the time of follow-up. CONCLUSIONS: Lifting posterior mitral annuloplasty using an innovative annuloplasty strip in mitral valve repair has a low rate of recurrent regurgitation or valve-related reoperation with rare relevant complications.

Mid-term results for a patch valvuloplasty technique to correct posterior leaflet prolapse.

BACKGROUND AND AIM OF THE STUDY: Most valve repair techniques require resection and multiple sutures. In the present study, a novel technique without resection for correction of posterior leaflet prolapse due to chordal elongation or rupture was employed, the aim being to evaluate the outcomes of a non-resecting valve repair technique in patients with posterior leaflet prolapse that caused significant mitral regurgitation (MR). METHODS: Between May 2008 and December 2010, a total of 90 consecutive patients with posterior leaflet prolapse (55 males, 35 females; mean age 51.5 ± 14.6 years) underwent patch valvuloplasty. The procedure involved suturing the free margin of the prolapsed leaflet, invagination of the folded leaflet tissue into the left ventricular side, coverage of the dimpled portion with a round bovine pericardial patch using a continuous suture technique, and reshaping of the posterior annulus using a 53- to 61-mm strip. All patients underwent postoperative echocardiography after a mean follow up of 41.9 ± 10.4 months. RESULTS: No early death occurred, but there was one late death due to a non-cardiac cause. At the last echocardiographic follow up, 81 patients (90%) showed none or trace MR, seven (7.8%) had mild MR, and two (2.2%) moderate MR. The mean mitral valve area was 2.4 ± 0.5 cm2 and the mean pressure gradient 2.8 ± 1.2 mmHg. No patient required reoperation due to recurrent or aggravated MR. CONCLUSION: In patients with posterior leaflet prolapse, the applied patch valvuloplasty technique was useful and reliable, showing excellent clinical and echocardiographic outcomes. Additional long-term evaluations with close follow up should be performed.

Assessment of the regurgitant orifice area in aortic regurgitation with dual-source CT: Comparison with cardiovascular magnetic resonance.

BACKGROUND: Regurgitant orifice area (ROA) measurements by cardiac CT have not been compared with a quantitative classification of aortic regurgitation (AR) severity based on regurgitant fraction by phase-contrast cardiovascular magnetic resonance (PC-CMR). OBJECTIVES: To compare ROA using dual-source CT (DSCT) with the grade of AR using PC-CMR for obtaining the cutoff values of the ROA allowing for grading of AR severity. METHODS: We retrospectively enrolled 208 patients (81 women, mean age 53.3 ± 14.4 years) with AR who underwent DSCT and CMR. DSCT data sets were reconstructed in 10% steps from 0% to 90% of the R-R interval to measure ROA. Grades of AR were determined by regurgitant fraction using PC-CMR. Receiver operating characteristic curves were calculated to differentiate between grades of AR and ROA. RESULTS: Sixty-three patients with mild AR, 80 with moderate AR, and 65 with severe AR by PC-CMR were enrolled. Quantification of the ROA by DSCT (mean, 27 ± 21 mm2) was significantly correlated with the grade of AR by PC-CMR (r = 0.83). In the receiver operating characteristic analysis, discrimination (mild vs moderate and moderate vs severe) among grades of AR with DSCT was accurate when cutoff ROAs of 15 mm2 and 23 mm2 in comparison with PC-CMR were used. CONCLUSIONS: The cutoff values of the ROA by DSCT allow for grading of AR severity determined by PC-CMR but are lower than those previously published, using transthoracic echocardiography as the reference standard. A multicenter study is necessary with a wide range of population for obtaining cutoff ROAs.

Characteristics of aortic valve dysfunction and ascending aorta dimensions according to bicuspid aortic valve morphology.

OBJECTIVE: To characterize aortic valve dysfunction and ascending aorta dimensions according to bicuspid aortic valve (BAV) morphology using computed tomography (CT) and surgical findings. METHODS: We retrospectively enrolled 209 patients with BAVs who underwent transthoracic echocardiography (TTE) and CT. BAVs were classified as anterior-posterior (BAV-AP) or lateral (BAV-LA) orientation of the cusps and divided according to the presence (raphe+) or absence (raphe-) of a raphe. Ascending aortic dimensions were measured by CT at four levels. RESULTS: BAV-AP was present in 129 patients (61.7%) and raphe+ in 120 (57.4%). Sixty-nine patients (33.0%) had aortic regurgitation (AR), 70 (33.5%) had aortic stenosis (AS), and 58 (27.8%) had combined AS and AR. AR was more common in patients with BAV-AP and raphe+; AS was more common with BAV-LA and raphe-.Annulus/body surface area and tubular portion/body surface area diameters in patients with BAV-AP (17.1 ± 2.3 mm/m(2) and 24.2 ± 5.3 mm/m(2), respectively) and raphe+ (17.3 ± 2.2 mm/m(2) and 24.2 ± 5.5 mm/m(2), respectively) were significantly different from those with BAV-LA (15.8 ± 1.9 mm/m(2) and 26.4 ± 5.5 mm/m(2), respectively) and raphe- (15.7 ± 1.9 mm/m(2) and 26.2 ± 5.4 mm/m(2), respectively). CONCLUSION: The morphological characteristics of BAV might be associated with the type of valvular dysfunction, and degree and location of an ascending aorta dilatation. KEY POINTS: • The BAV-AP type had more frequent aortic regurgitation, raphe, and a larger aortic annulus. • BAV without raphe had more frequent aortic stenosis and mid-ascending aorta dilatation. • CT allows assessment of the morphological characteristics of BAV and associated aortopathy.

Fused aortic valve without an elliptical-shaped systolic orifice in patients with severe aortic stenosis: cardiac computed tomography is useful for differentiation between bicuspid aortic valve with raphe and tricuspid aortic valve with commissural fusion.

OBJECTIVE: The objective is to determine cardiac computed tomography (CCT) features capable of differentiating between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) in severe aortic stenosis (AS) patients with fused cusp and without elliptical-shaped systolic orifices. METHODS: We retrospectively enrolled 53 patients who had severe AS with fused cusps and without an elliptical-shaped systolic orifice on CCT and who had undergone surgery. CCT features were analyzed using: 1) aortic valve findings including cusp size, cusp area, opening shape, midline calcification, fusion length, calcium volume score, and calcium grade; 2) diameters of ascending and descending aorta, and main pulmonary artery; and 3) rheumatic mitral valve findings. The variables were evaluated using univariate and multivariate logistic regression analyses. RESULTS: At surgery, 19 patients had BAV and 34 had TAV. CCT features including uneven cusp size, uneven cusp area, round-shaped systolic orifice, longer cusp fusion, and dilatation of ascending aorta were significantly associated with BAV (P < 0.05). In particular, fusion length (OR, 1.76; P = 0.001), uneven cusp area (OR, 10.46; P = 0.012), and midline calcification (OR, 0.08; P = 0.013) were strongly associated with BAV. CONCLUSION: CCT provides diagnostic clues that helps differentiate between BAV with raphe and TAV with commissural fusion in patients with severe AS. KEY POINTS: • Accurate morphologic assessment of the aortic valve is important for treatment planning. • It is difficult to differentiate BAV from TAV with a fused cusp. • CCT provides diagnostic clues for the differentiation of BAV and TAV.

Novel Early Predictor of Acute Kidney Injury after Open Heart Surgery under Cadiopulmonary Bypass Using Plasma Neutrophil Gelatinase-Associated Lipocalin.

BACKGROUND: Open heart surgery using cardiopulmonary bypass (CPB) is considered one of the most frequent surgical procedures in which acute kidney injury (AKI) is a frequent and serious complication. The aim of the present study was to evaluate the efficiency of neutrophil gelatinase-associated lipocalin (NGAL) as an early AKI biomarker after CPB in cardiac surgery (CS). METHODS: Thirty-seven adult patients undergoing CS with CPB were included in this retrospective study. They had normal preoperative renal function, as assessed by the creatinine (Cr) level, NGAL level, and estimated glomerular filtration rate. Serial evaluation of serum NGAL and Cr levels was performed before, immediately after, and 24 hours after the operation. Patients were divided into two groups: those who showed normal immediate postoperative serum NGAL levels (group A, n=30) and those who showed elevated immediate postoperative serum NGAL levels (group B, n=7). Statistical analysis was performed using Statistical Package for the Social Sciences version 18. RESULTS: Of the 37 patients, 6 (6/37, 16.2%) were diagnosed with AKI. One patient belonged to group A (1/30, 3.3%), and 5 patients belonged to group B (5/7, 71.4%). Two patients in group B (2/7, 28.5%) required further renal replacement therapy. Death occurred in only 1 patient (1/37, 2.7%), who belonged to group B. CONCLUSION: The results of this study suggest that postoperative plasma NGAL levels can be used as an early biomarker for the detection of AKI following CS using CPB. Further studies with a larger sample size are needed to confirm our results.

Efficacy and safety of dexmedetomidine for postoperative delirium in adult cardiac surgery on cardiopulmonary bypass.

BACKGROUND: Delirium after cardiac surgery is associated with serious long-term negative outcomes and high costs. The aim of this study is to evaluate neurobehavioral, hemodynamic, and sedative characteristics of dexmedetomidine, compared with the current postoperative sedative protocol (remifentanil) in patients undergoing open heart surgery with cardiopulmonary bypass (CPB). METHODS: One hundred and forty two eligible patients who underwent cardiac surgery on CPB between April 2012 and March 2013 were randomly divided into two groups. Patients received either dexmedetomidine (range, 0.2 to 0.8 µg/kg/hr; n=67) or remifentanil (range, 1,000 to 2,500 µg/hr, n=75). The primary end point was the prevalence of delirium estimated daily via the confusion assessment method for intensive care. RESULTS: When the delirium incidence was compared with the dexmedetomidine group (6 of 67 patients, 8.96%) and the remifentanil group (17 of 75 patients, 22.67%) it was found to be significantly less in the dexmedetomidine group (p<0.05). There were no statistically significant differences between two groups in the extubation time, ICU stay, total hospital stay, and other postoperative complications including hemodynamic side effects. CONCLUSION: This preliminary study suggests that dexmedetomidine as a postoperative sedative agent is as sociated with significantly lower rates of delirium after cardiac surgery.

Cardiac parasitic infection in trichinellosis associated with right ventricle outflow tract obstruction.

Here, we present a rare case of cardiac parasitic infection found in an adult female patient who had the symptoms of dyspnea upon exertion. She was diagnosed with a double-chambered right ventricle due to infundibular hypertrophy confirmed by transthoracic echocardiography and cardiac computed tomography. We performed surgery of infundibulectomy around the pulmonary valve. In the end, histopathological findings of the resected infundibular muscle demonstrated trichinellosis, a type of roundworm infection.

Mid-term results in patients having tricuspidization of the quadricuspid aortic valve.

BACKGROUND: Quadricuspid aortic valve (QAV) is a rare congenital anomaly. We investigate the mid-term results of aortic valve reconstruction by tricuspidization in patients with QAV. METHODS: We analyzed the outcome of eight consecutive patients who underwent aortic valve reconstruction surgery (AVRS) with pericardial leaflets with symptomatic quadricuspid aortic valve (QAV) disease between December 2007 and May 2012. AVRS consists of leaflet reconstruction and fixation of the sino-tubular junction in order to maintain coaptation of the new valve. RESULTS: Six males and two females were included; ages ranged from 19 to 63 years (mean age, 51 years). According to Hurwitz and Roberts's classification, three patients had type A, three patients had type B, one patient had type C, and one patient had type E. All patients had significant aortic regurgitation (AR): moderate in three patients, moderate to severe in one patient, and severe in four patients. Concomitant ascending aorta wrapping with an artificial vascular graft was performed in one case. There was no occurrence of mortality during the follow-up period (42.4 ± 18.0 months). No redo-operation was required. The NYHA functional class showed improvement from 2.1 ± 0.2 to 1.1 ± 0.2 (p= 0.008). The latest echocardiograms showed AR absent or trivial in seven patients, and mild in one patient. The aortic valve orifice area index (AVAI) was 1.03 ± 0.49 cm2/m2. Compared with preoperative echocardiograms, the left ventricular (LV) ejection fraction showed improvement from 57.6 ± 17.0 to 63.7 ± 13.2% (p=0.036); the end-diastolic and end-systolic LV dimensions showed a significant decrease, from 63.5 ± 9.6 to 49.5 ± 3.1 mm (p=0.012) and 43.6 ± 11.8 to 32.1 ± 5.4 mm (p=0.012), respectively. CONCLUSION: In patients with QAV, AVRS with tricuspidization showed satisfactory early and mid-term results. Long-term follow-up will be necessary in order to study the durability of AVRS; however, it can be considered as a potential standard procedure.