Impact of Everolimus Initiation and Corticosteroid Weaning During Acute Phase After Heart Transplantation on Clinical Outcome: Data from the Korean Organ Transplant Registry (KOTRY).

The effect of changes in immunosuppressive therapy during the acute phase post-heart transplantation (HTx) on clinical outcomes remains unclear. This study aimed to investigate the effects of changes in immunosuppressive therapy by corticosteroid (CS) weaning and everolimus (EVR) initiation during the first year post-HTx on clinical outcomes. We analyzed 622 recipients registered in the Korean Organ Transplant Registry (KOTRY) between January 2014 and December 2021. The median age at HTx was 56 years (interquartile range [IQR], 45-62), and the median follow-up time was 3.9 years (IQR 2.0-5.1). The early EVR initiation within the first year post-HTx and maintenance during the follow-up is associated with reduced the risk of primary composite outcome (all-cause mortality or re-transplantation) (HR, 0.24; 95% CI 0.09-0.68; p < 0.001) and cardiac allograft vasculopathy (CAV) (HR, 0.39; 95% CI 0.19-0.79; p = 0.009) compared with EVR-free or EVR intermittent treatment regimen, regardless of CS weaning. However, the early EVR initiation tends to increase the risk of acute allograft rejection compared with EVR-free or EVR intermittent treatment.

A Case of Heart Transplantation for Fulminant Myocarditis After ChAdOx1 nCoV-19 Vaccination.

Vaccines have become the mainstay of management against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019; COVID-19) in the absence of effective antiviral therapy. Various adverse effects of COVID-19 vaccination have been reported, including cardiovascular complications such as myocarditis or pericarditis. Herein, we describe clinical records of a 63-year woman with fulminant myocarditis following ChAdOx1 nCoV-19 vaccination that was salvaged by heart transplantation. She complained chest pain, nausea, vomiting, and fever after the second vaccination. After the heart transplantation, the patient died due to necrotizing pneumonia on the 54th day of onset. Fulminant myocarditis is very rare after ChAdOx1 nCoV-19 vaccination but can be fatal.

Early experience of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients with cardiogenic shock.

INTRODUCTION: Pump-controlled retrograde trial off has recently been introduced as an effective method for weaning from veno-arterial extracorporeal membrane oxygenation in pediatric patients. However, studies on pump-controlled retrograde trial off in adults are still lacking. Thus, this study aimed to examine the outcomes of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients. METHODS: Between January 2018 and July 2019, 87 consecutive adult patients underwent veno-arterial extracorporeal membrane oxygenation support, of whom 47 (54.0%) underwent pump-controlled retrograde trial off for weaning from extracorporeal membrane oxygenation and were enrolled in this study. The pump-controlled retrograde trial off results, extracorporeal membrane oxygenation reapplication rate, and clinical outcomes were analyzed. RESULTS: Of the 47 patients, 38 (80.9%) were weaned from veno-arterial extracorporeal membrane oxygenation on the first attempt of pump-controlled retrograde trial off, 5 (10.6%) on the second attempt, and 4 (8.5%) on the third attempt. Three patients were converted to venovenous extracorporeal membrane oxygenation by desaturation but had stable blood pressure during pump-controlled retrograde trial off. No extracorporeal membrane oxygenation reapplication was performed within 3 days after removal, and two patients underwent veno-arterial extracorporeal membrane oxygenation during follow-up. No complications associated with pump-controlled retrograde trial off occurred during the weaning process, including thromboembolic events. Five in-hospital deaths (10.6%) occurred after weaning from extracorporeal membrane oxygenation. CONCLUSION: Pump-controlled retrograde trial off is an effective method to safely wean from veno-arterial extracorporeal membrane oxygenation in adult patients. It is simple and can be easily implemented without additional invasive procedures and may help prevent deterioration of the cardiovascular system after weaning from veno-arterial extracorporeal membrane oxygenation.

Early extubation after left ventricular assist device implantation in a patient with Duchenne muscular dystrophy: a case report.

Management of Duchenne muscular dystrophy (DMD) cardiomyopathy is increasingly important for the survival of these patients. Left ventricular assist device (LVAD) is an alternative treatment for refractory heart failure in DMD. A 20-year-old man with DMD and dilated cardiomyopathy underwent surgery for LVAD implantation. Respiratory failure may occur due to muscle weakness after surgery under general anesthesia in patients with DMD, and weaning from mechanical ventilation may be delayed or difficult. Considering the application of fast-track anesthesia (FTA), preoperative pulmonary rehabilitation which includes thoracic expansion exercise, air stacking exercise with manual resuscitation bag and manually assisted cough technique, hight-frequency chest wall oscillation, and mechanical insufflation-exsufflation was performed. We report on a patient with DMD in whom FTA and early extubation within 6 h after LVAD implantation was successfully performed without complications.

Three-Dimensional Computed Tomographic Analysis of Normal and Aneurysmal Aortic Roots: Is There a Specific Geometric Pattern in the Aortic Root?

Current knowledge of the aortic root geometric anatomy and its surgical implications remain limited. We analyzed multiple predefined parameters of the aortic root to increase our understanding of the geometric changes that occur in normal and aneurysmal transformations. Between November 2003 and September 2015, the aortic roots of 107 healthy subjects (control group) and 105 annuloaortic ectasia (AAE) patients (AAE group) were analyzed using multiplanar reformatted computed tomographic images. The intercommissural distance (ICD), sinus width (SW), and sinus volume (SV) of the left (LCS), right (RCS), and noncoronary sinuses (NCS) of Valsalva were adopted as study parameters. In the control group, all study parameters of the LCS were smaller than those of the RCS and the NCS. In the AAE group, all parameters of the LCS were significantly smaller than those of the RCS or NCS, but the RCS and NCS parameters were similar. Proportionately less LCS enlargement relative to either the RCS or NCS was observed in root aneurysm(AAE group) than in the control group. We observed a distinct aortic root geometric pattern which was characterized by the LCS being smaller than either the RCS or NCS, while the latter were similar. This geometric configuration was significantly accentuated in AAE patients due to the greater disproportionate disparity in the LCS relative to either the RCS or NCS than in the roots of normal control subjects. Clin. Anat. 32:117-123, 2019. © 2019 Wiley Periodicals, Inc.

Incidence and Distribution of Cerebral Embolism After Cardiac Surgery According to the Systemic Perfusion Strategy　- A Diffusion-Weighted Magnetic Resonance Imaging Study.

BACKGROUND: Stroke is a major concern in minimally invasive cardiac surgery, so we investigated the incidence and risk factors of cerebral embolism according to the systemic perfusion strategy under thorough imaging assessment.Methods and Results:Between November 2011 and May 2015, 315 cardiac surgery patients who underwent preoperative computed tomography angiography (CTA) as a routine evaluation were enrolled. The incidence and distribution of cerebral embolism were analyzed with routine postoperative brain diffusion-weighted magnetic resonance imaging (DW-MRI) examination. Anterograde perfusion was used in 103 patients (group A), and retrograde perfusion was performed in 212 patients (group R). Operative deaths, incidence of clinical stroke (group A: 0%, group R: 0.5%, P=0.77), and rate of cerebral embolism (group A: 35.9%, group R: 26.4%, P=0.08) were comparable. The median number of new embolic lesions detected by MRI per patient (group A: 2, group R: 2, P=0.16), maximal diameter of the lesion (group A: 6.5 mm, group R: 6.0 mm, P=0.97), and anatomic distribution of the lesion were similar between groups. In the multivariate analysis, hypertension, emergency status, atherosclerosis grade 3 or 4 (intimal thickening >4 mm), and cardiopulmonary bypass time were independent risk factors for postoperative cerebral embolism, but retrograde perfusion was not. CONCLUSIONS: According to the results of postoperative DW-MRI, retrograde perfusion itself might not increase the incidence of postoperative cerebral embolism in properly selected cardiac surgery patients undergoing routine preoperative CTA examination.

Impact of Sarcopenia on Outcomes of Minimally Invasive Cardiac Surgery.

Sarcopenia is an objective marker of poor outcome following cardiac surgery through median sternotomy. However, the clinical impact of sarcopenia after minimally invasive cardiac surgery (MICS) has not been well established. This study aimed to analyze the influence of sarcopenia on the early and late outcomes following MICS. We retrospectively examined 1248 patients who underwent MICS via right mini-thoracotomy or upper sternotomy between February 2009 and April 2020. Patients older than 65 years who underwent preoperative computed tomography were enrolled. Sarcopenia was defined as the lowest sex-specific quartile of the body surface area adjusted psoas muscle area. The early operative and late survival outcomes were compared, and the predictor of late composite outcome was analyzed using Cox proportional regression model. Early and late composite outcomes in both groups were also compared. A total of 367 patients were classified into the sarcopenia (n = 92) or non-sarcopenia (n = 275) group. Patients in the sarcopenia group were older, and had lower preoperative hemoglobin and albumin levels. They had higher estimated surgical mortality, but similar early mortality and major morbidity. The survival and late composite outcome were comparable between the two groups. Sarcopenia was neither an independent predictor of late death nor a composite outcome in the multivariable model. After MICS, patients with sarcopenia displayed comparable perioperative outcomes and survival. The clinical impact of sarcopenia on postoperative outcomes might be alleviated by MICS and early recovery protocol after MICS. MICS could be a reasonable approach for elderly patients with sarcopenia.

Influence of hepatic dysfunction in patients who underwent tricuspid valve surgery.

Background: Hepatic dysfunction (HD) is frequently associated with chronic tricuspid regurgitation (TR), and is a risk factor for TR surgery. Late referral of patients with TR is associated with the progression of TR and HD, as well as an increase in surgical morbidity and mortality. Many patients with severe TR suffer from HD; however, their clinical impact is not well documented. Methods: This retrospective review was conducted between October 2008 and July 2017. In total, 159 consecutive patients underwent surgery for TR; 101 with moderate to severe TR were included. We divided patients into N (normal liver function; n=56) and HD (HD; n=45) groups. HD was defined as clinically or radiologically diagnosed liver cirrhosis, or a preoperative Model for End-Stage Liver Disease (MELD)-XI score ≥13. Perioperative data were compared between groups, and changes in the MELD score following TR surgery were estimated in the HD group. Long-term survival rates were analyzed, and analyses were performed to obtain the assessment tool and cutoff value to determine the degree of HD affecting late mortality. Results: The preoperative demographics of both groups were similar, excluding the presence of HD. The EuroSCORE II, MELD score, and prothrombin time international normalization ratio were significantly higher in the HD group, and although early mortality was comparable between groups [N group: 0%, HD group: 2.2% (n=1); P=0.446], intensive care unit and hospital stays were significantly longer in the HD group. The MELD score in the HD group temporarily increased immediately after surgery, and then decreased. The long-term survival rates were significantly lower in the HD group. The most suitable tool for predicting late mortality was the MELD-XI score, with a cutoff value of 13 points. Conclusions: Surgery for patients with severe TR can be performed with relatively low morbidity and operative mortality, regardless of associated HD. MELD scores significantly improved after TR surgery in patients with HD. Even with favorable early outcomes, compromised long-term survival with HD suggests the need to develop an assessment tool that can evaluate the appropriate timing for TR surgery.

Surgical Outcomes of Cardiac Myxoma Resection Through Right Mini-Thoracotomy.

Background: With recent advances in cardiac surgery through minimal access, mini-thoracotomy has emerged as an excellent alternative for cardiac myxoma resection. This study analyzed the surgical results of this approach, focusing on postoperative cerebral embolism and tumor recurrence. Methods: We retrospectively reviewed 64 patients (mean age, 56.0±12.1 years; 40 women) who underwent myxoma resection through mini-thoracotomy from October 2008 to July 2020. We conducted femoral cannulation and antegrade cardioplegic arrest in all patients. Patient characteristics and perioperative data, including brain diffusion-weighted magnetic resonance imaging (DWI) findings, were collected. Medium-term echocardiographic follow-up was performed. Results: Thirteen patients (20.3%) had a history of preoperative stroke, and 7 (11.7%) had dyspnea with New York Heart Association functional class III or IV. Sixty-one cases (95.3%) had myxomas in the left atrium. The mean cardiopulmonary bypass and cardiac ischemic times were 69.0±28.6 and 34.1±15.0 minutes, respectively. Sternotomy conversion was not performed in any case, and 50 patients (78.1%) were extubated in the operating room. No early mortality or postoperative clinical stroke occurred. Postoperative DWI was performed in 32 (53%) patients, and 7 (22%) showed silent cerebral embolisms. One patient underwent reoperation for tumor recurrence during the study period; in that patient, a genetic study confirmed the Carney complex. Conclusion: Mini-thoracotomy for cardiac myxoma resection showed acceptable clinical and neurological outcomes. In the medium-term echocardiographic follow-up, reliable resection was proven, with few recurrences. This approach is a promising alternative for cardiac myxoma resection.

Direct Extracorporeal Membrane Oxygenation Bridged Heart Transplantation: The Importance of Multi-Organ Failure.

Background and Objectives: Recently, approximately 40% of all heart transplantation (HTx) in South Korea are performed using the direct extracorporeal membrane oxygenation (ECMO) bridging method. We conducted a study to examine the clinical outcome of direct ECMO-bridged HTx and to investigate the impact of multi-organ failure (MOF). Methods: From June 2014 to September 2022, a total of 96 adult patients who underwent isolated HTx at a single tertiary hospital were included in the study. The patients were sub-grouped into ECMO (n=48) and non-ECMO group (n=48), and the ECMO group was subdivided into awake (n=22) and non-awake (n=26) groups based on mechanical ventilator (MV) dependency. Baseline characteristics, 30-day, and 1-year mortality were analyzed retrospectively. Results: The 1-year survival rate was significantly lower in the ECMO group (72.9% vs. 95.8%, p=0.002). There was a significant difference in the 30-day survival rate between the awake and non-awake ECMO groups (81.8% vs. 65.4%, p=0.032). In the univariate analysis of logistic regression for 1-year mortality, the odds ratio was 8.5 for ECMO bridged HTx compared to the non-ECMO group, 12.3 in patients who required MV (p=0.003), and 23 with additional hemodialysis (p<0.001). Conclusions: Patients who required MV in ECMO bridged HTx showed higher preoperative MOF rates and early mortality than those extubated. When considering ECMO bridged HTx, the severity of MOF should be thoroughly investigated, and careful patient selection is necessary.

The Clinical Outcomes of Marginal Donor Hearts: A Single Center Experience.

BACKGROUND AND OBJECTIVES: Although the shortage of donor is a common problem worldwide, a significant portion of unutilized hearts are classified as marginal donor (MD) hearts. However, research on the correlation between the MD and the prognosis of heart transplantation (HTx) is lacking. This study was conducted to investigate the clinical impact of MD in HTx. METHODS: Consecutive 73 HTxs during 2014 and 2021 in a tertiary hospital were analyzed. MD was defined as follows; a donor age >55 years, left ventricular ejection fraction <50%, cold ischemic time >240 minutes, or significant cardiac structural problems. Preoperative characteristics and postoperative hemodynamic data, primary graft dysfunction (PGD), and the survival rate were analyzed. Risk stratification by Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score was performed to examine the outcomes according to the recipient state. Each group was sub-divided into 2 risk groups according to the IMPACT score (low <10 vs. high ≥10). RESULTS: A total of 32 (43.8%) patients received an organ from MDs. Extracorporeal membrane oxygenation was more frequent in the non-MD group (34.4% vs. 70.7, p=0.007) There was no significant difference in PGD, 30-day mortality and long-term survival between groups. In the subgroup analysis, early outcomes did not differ between low- and high-risk groups. However, the long-term survival was better in the low-risk group (p=0.01). CONCLUSIONS: The outcomes of MD group were not significantly different from non-MD group. Particularly, in low-risk recipient, the MD group showed excellent early and long-term outcomes. These results suggest the usability of selected MD hearts without increasing adverse events.

Technical Aspects of Combined Heart-Lung Transplantation.

Although organ transplants have become quite common, combined heart-lung transplantation (CHLTx) is unfamiliar at most institutions. While the remarkable rate of development in treatment options, such as drugs and mechanical circulatory support, have reduced the need for CHLTx, it remains the sole treatment option for a subset of patients with end-stage cardiopulmonary failure. For many cardiothoracic surgeons, CHLTx is not technically new or difficult, but it does pose challenges due to its low frequency and relative complexity. Thus, this review aims to describe the CHLTx technique in technical detail using the existing literature.

Control of Femoral Cannulation with a ProGlide Pre-Closure Device during Cardiac Surgery: Is It Reliable?

BACKGROUND: The use of ProGlide as a percutaneous vascular closure device in cardiac surgery remains inconclusive. This study investigated the clinical outcomes of using Pro- Glide in the percutaneous cannulation of femoral vessels in adult cardiac surgery. METHODS: From September 2017 to July 2018, 131 consecutive patients underwent femoral vessel cannulation during cardiac surgery. The ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA) with percutaneous cannulation was used in 118 patients (mean age, 55.7±15.5 years). The accessibility of femoral cannulation was evaluated through preoperative computed tomography. For cannulation, sonography was routinely used. The postoperative ankle-brachial index (ABI) was used to evaluate femoral artery stenosis. RESULTS: Of the 118 patients, 112 (94.9%) and 6 (5.1%) underwent minimally invasive cardiac surgery and median sternotomy, respectively. Most femoral cannulations were performed on the right side (98.3%) using 15F to 19F arterial cannulas. The technical success rate of cannulation with ProGlide was 99.2%, with no delayed bleeding or cannulation site-related complications during hospitalization. During follow-up, only 1 patient showed femoral artery stenosis with claudication and was treated with interventional balloon angioplasty. The postoperative ABI revealed no significant difference in functional stenosis between the cannulation and non-cannulation sides (n=86; cannulation vs. non-cannulation, 1.2±0.1 vs. 1.1±0). CONCLUSION: Percutaneous femoral cannulation with ProGlide was safe and feasible in adult cardiac surgery. This technique may be a good alternative option in patients requiring femoral vessel cannulation for cardiac surgery.

Cardiac myxoma misdiagnosed as infective endocarditis: a case of Carney complex.

BACKGROUND: Infective endocarditis and cardiac myxoma have common features including fever, systemic embolism and intra-cardiac masses. For this reason, these diseases are often misdiagnosed one for another despite proper imaging studies. Herein, we report a case of suspected infective endocarditis in a patient with acute stroke, fever and a mass adjacent to the mitral valve. CASE PRESENTATION: A 24-year-old male patient presented with recurrent fever and stroke. In view of a history of Cushing syndrome and a mobile mass in the left atrium, infective endocarditis was highly suspected. He was transferred for emergency cardiac surgical intervention. During surgery, intraoperative transesophageal echocardiography revealed a 7 cm mass attached to the interatrial septum. The mass was excised through right mini-thoracotomy and pathological examination confirmed the presence of a myxoma. Based on the above clinical findings and genetic analysis, the diagnosis of Carney complex was confirmed. CONCLUSIONS: Infective endocarditis and cardiac myxoma have common features and can be misdiagnosed. If a young patient presenting with embolic stroke had a history of an endocrine neoplasm, Carney complex should be considered in the differential diagnosis of infective endocarditis.

Effects of Preoperative Autologous Blood Donation in Patients Undergoing Minimally Invasive Cardiac Surgery.

BACKGROUND: Preoperative autologous blood donation (PABD) is a conservation strategy for reducing allogenic blood transfusion (ABT) during minimally invasive cardiac surgery (MICS). We aimed to evaluate the effects of PABD on the frequency of ABT and clinical outcomes in patients undergoing MICS. METHODS: We enrolled 113 patients (47.8±13.1 years, 50 men) undergoing MICS without preoperative anemia (hemoglobin >11 g/dL) between 2014 and 2017. Of these patients, 69 (the PABD group) donated autologous blood preoperatively and were compared to the non-PABD group (n=44). We analyzed the frequency of perioperative ABT and clinical outcomes. RESULTS: Baseline characteristics did not significantly differ between groups, although preoperative hemoglobin levels were lower in the PABD group. All operations were performed using a minimally invasive approach. Patients' surgical profiles were similar. There were no cases of mortality or significant differences in early postoperative outcomes. During the early postoperative period, hemoglobin levels were higher in the PABD group. No significant difference was found in the frequency of ABT. CONCLUSION: Although the PABD group had higher postoperative hemoglobin levels, there was no clear clinical benefit in the early postoperative period, despite a great deal of effort and additional cost. Additional PABD in the setting of strict policies for blood conservation was ineffective in reducing ABT for young and relatively healthy patients who underwent MICS.

Robotic-Assisted Surgical Ablation of Atrial Fibrillation Combined With Mitral Valve Surgery.

BACKGROUND: Data on robotic-assisted surgical atrial fibrillation (AF) ablation in patients undergoing mitral valve (MV) operations are lacking. This study aimed to evaluate early and late outcomes after robotic-assisted ablation of AF combined with MV surgery. METHODS: Between 2007 and 2017, this study enrolled 94 patients (age: 53.9 ± 12.7 years; 67 men) undergoing AF ablation by using an argon-based flexible cryoablation system during robotic-assisted MV surgical procedures. Persistent (n = 34, 36.2%) or long-standing persistent (n = 38, 40.4%) AF was present in most patients. Primary valve procedures included isolated mitral repair in 58 patients, isolate mitral replacement in 2 patients, and combined mitral and tricuspid repair in 34 patients. RESULTS: Sixty patients (63.8%) received left-side-only AF ablation, whereas the others (n = 34, 36.2%) received biatrial ablation. The operation times for cardiopulmonary bypass and aortic cross-clamping were 222.7 ± 57.8 minutes and 134.1 ± 30.4 minutes, respectively. No early death was seen. Major early complications included neurologic injury in 2 patients (2.1%) and low cardiac output syndrome in 2 patients (2.1%). No patients required permanent pacemaker implantation. Early AF occurred in 14 patients (14.9%) during a postablation blanking period (90 days). During a median follow-up of 49.6 months (quartiles 1 to 3: 17.2 to 79.4 months, 95.7% complete), there were two late deaths (0.49% per patient-year) and one stroke (0.25% per patient-year). Five-year survival was greater than 96%, and results from largely electrocardiograms showed a low recurrence of AF (2.2% at 1 year, 6.7% at 5 years). CONCLUSIONS: Surgical AF ablation with the use of robotic-assistance in the setting of mitral valve surgery showed excellent safety and favorable long-term clinical outcomes.

Impact of Valve Replacement on Long-Term Survival in Asymptomatic Patients With Severe Aortic Stenosis.

Aortic valve (AV) replacement (AVR) is the only effective treatment for severe aortic stenosis (AS). However, survival benefits by performing AVR in asymptomatic AS patients with preserved left ventricular (LV) function remains controversial. This study included 468 patients (aged 64.2 ± 13.0 years, 232 women) with preserved LV function (≥50%) and severe AS (AV area ≤1.0 cm2, peak trans-AV velocity [Vmax] ≥4.0 m/s, or mean AV pressure gradient ≥40 mm Hg) between 2000 and 2015. AVR was performed in 221 (47.2%) patients early (within 3 months; n = 130, 27.8%) or during follow-up (n = 91, 19.4%), whereas the remainder (n = 247) received medical treatment. Time-dependent Cox regression analyses were performed to determine the impact of AVR on long-term survival outcomes. During a median follow-up of 60.9 months (quartile 1 to 3, 29.9 to 107.0 months), 72 (15.4%) patients developed AS-related symptoms and 146 (31.2%) died. On time-dependent Cox models, AVR was associated with a significant risk reduction in all-cause death (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.40 to 0.97; p = 0.036) and cardiac death (HR, 0.59; 95% CI, 0.35 to 0.995; p = 0.048) after adjusting for significant contributors to mortality. Survival benefits by performing AVR were manifested in most risk subgroups. In conclusion, AVR in asymptomatic severe AS patients with preserved LV function resulted in significant survival benefits, suggesting that early recruitment for AVR may be warranted before ventricular dysfunction or symptom development.

The Treatment of Left Atrial Appendage Aneurysm by a Minimally Invasive Approach.

Left atrial appendage (LAA) aneurysm is a rare, pathologic condition that may lead to atrial tachyarrhythmia or thromboembolic events. A 49-year-old man presented with aggravated palpitation and dizziness. He suffered from refractory atrial fibrillation despite a previous history of radiofrequency catheter ablation. Echocardiography revealed a 57-mm LAA aneurysm. Surgical ablation was performed through a right mini-thoracotomy, and the LAA aneurysm was obliterated with a 50-mm AtriClip (Atricure Inc., Westchester, OH, USA). However, follow-up computed tomography showed residual communication, so the patient is still taking warfarin. We report that a minimally invasive strategy for treating LAA aneurysm can be considered, but incomplete closure may occur; thus, caution is needed.

On-pump beating heart versus conventional coronary artery bypass grafting: comparative study on early and long-term clinical outcomes.

BACKGROUND: We reviewed our experience with on-pump beating (OPB) heart coronary artery bypass grafting (CABG) to evaluate the impacts of obviating aortic cross-clamping and cardioplegic arrest on clinical outcomes compared with conventional CABG (C-CABG). METHODS: Between 2006 and 2012, elective isolated cardiopulmonary bypass (CPB)-assisted CABG was consecutively performed in 645 patients (mean patient age 63.3±9.1 years, 471 women) with 254 (39.4%) undergoing OPB-CABG and 391 (60.6%) undergoing C-CABG. The early and long-term clinical outcomes were compared between the two groups after adjusting for risk profiles through propensity score (PS) analyses. RESULTS: The OPB-CABG group presented significant morbidities more frequently than the C-CABG group, including severe chronic kidney disease (CKD) (P=0.026), severe chest pain (P<0.001), and poor left ventricular function (P<0.001). Early mortality occurred in 6 (2.4%) and 2 (0.5%) patients in the OPB- and C-CABG group, respectively (P=0.087). The number of distal anastomosis was comparable between the two groups (3.0±0.9 vs. 3.0±1.0, P=0.816). After PS matching, the incidence of major complications such as stroke (P>0.99) and new-onset dialysis (P=0.109) was comparable. During a median follow-up of 81.0 months (quartiles 1-3, 66.6-95.0 months), 118 patients died and the PS-matched models showed no significant between-group differences in the risk of overall death [hazard ratio (HR), 1.19; 95% confidence interval (CI), 0.72-1.95; P=0.507] and major adverse cardiac events (MACE) (HR, 1.49; 95% CI, 0.67-3.31; P=0.328). CONCLUSIONS: The OPB strategy may be as safe and effective as the conventional strategy during CABG among patients with similar risk profiles. A prospective randomized trial is warranted to better ascertain the beneficial impact of OPB-CABG as both a viable and a durable alternative strategy to C-CABG.

Concomitant mitral valve surgery in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting.

BACKGROUND: The clinical benefits of a concomitant mitral valve (MV) surgery in patients with moderate ischemic mitral regurgitation (iMR) undergoing coronary artery bypass grafting (CABG) remain controversial. METHODS: The study involved 710 patients (mean age, 65.0±8.9 years; 504 males) with moderate iMR undergoing CABG between 1990 and 2015. Of these, 116 (16.3%) patients underwent a concomitant MV surgery (MVS; replacement in 10, repair in 106) and 594 (83.7%) underwent CABG only. Clinical and echocardiographic outcomes were compared before and after adjustment with the use of propensity score (PS) analyses. RESULTS: Early mortality occurred in 22 (3.7%) and 13 (11.2%) patients in CABG-only and CABG with MVS group, respectively (P=0.001). After adjustment, CABG with MVS group showed significantly increased risks of early death (P<0.001), low cardiac output syndrome (LCOS) (P=0.001) and surgical bleeding (P=0.014). During a median follow-up of 78.0 months (quartile 1-3, 33.6-115.9 months), overall mortality occurred in 286 (40.3%) patients. The addition of an MV surgery showed an increased risk of overall mortality [hazard ratio (HR), 1.34; 95% confidence interval (CI), 0.99-1.80; P=0.055], which became comparable 1 year after surgery on landmark survival analysis (HR, 0.94; 95% CI, 0.64-1.39; P=0.772). Improved left ventricular (LV) ejection fraction and LV reverse remodeling were observed in both groups without significant intergroup differences. CONCLUSIONS: The addition of a concomitant MV surgery increased the risk of early mortality and complications in patients with moderate iMR undergoing CABG. In long-term clinical and echocardiographic outcomes, a concomitant MV surgery seemed to confer no significant clinical benefits.