Effect of Preoperative Left Ventricular Mass on Outcomes After Aortic Valve Replacement for Aortic Regurgitation.

BACKGROUND: We determined the left ventricular mass index (LVMI) cut-off value for the risk of major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing aortic valve replacement (AVR) for aortic regurgitation (AR) and investigated the effect of preoperative left ventricular remodeling on long-term outcomes postoperatively. METHODS AND RESULTS: Of the 1,580 patients who underwent surgical AVR at Shiga University of Medical Science between January 2002 and December 2022, we retrospectively analyzed data for 263 patients who underwent surgery for AR. The receiver operating characteristic curve showed that the cut-off value of preoperative LVMI for the incidence of MACCE was 200 g/m2(area under the curve=0.692). We compared postoperative outcomes between patients with preoperative LVMI >200 g/m2(n=92) and those with preoperative LVMI ≤200 g/m2(n=171) after adjusting for preoperative characteristics using inverse probability of treatment weighting. The mean (±SD) follow-up period was 6.9±5.1 years. The rate of MACCE at 10 years was significantly higher in patients with preoperative LVMI >200 g/m2than in those with preoperative LVMI ≤200 g/m2(25.6% vs. 13.5%; P=0.020). In multivariable Cox models, preoperative LVMI >200 g/m2was significantly associated with a higher risk of MACCE (hazard ratio 2.356, P=0.006). CONCLUSIONS: Preoperative LVMI >200 g/m2was associated with a higher rate of MACCE in patients undergoing AVR for AR.

Off-Pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Octogenarians.

BACKGROUND: We compared postoperative outcomes in octogenarians who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).Methods and Results: Among 1,532 patients who underwent isolated coronary artery bypass grafting between 2002 and 2021, 173 octogenarians were analyzed retrospectively. After inverse probability of treatment weighting, we found no statistically significant difference regarding patients' preoperative characteristics. No patient experienced deep sternal wound infection. More patients in the single than bilateral ITA group died within 30 days after surgery (5.0% vs. 0%, respectively; P=0.003). The mean follow-up duration was 4.2 years. At 5 years, the freedom from overall death following bilateral versus single ITA grafting was 78.2% and 53.7%, respectively (log-rank test, P=0.003), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 67.9% and 44.8% respectively (log-rank test, P=0.002). In multivariable Cox models, bilateral ITA grafting was significantly associated with a lower risk of overall death (hazard ratio [HR] 0.555; 95% confidence interval [CI] 0.342-0.903; P=0.018) and MACCE (HR 0.586; 95% CI 0.376-0.913; P=0.018). CONCLUSIONS: Compared with single ITA grafting, off-pump skeletonized bilateral ITA grafting is associated with lower rates of overall death and MACCE in octogenarians undergoing CABG and does not increase the risk of deep sternal wound infection.

[Total Arch Replacement with Open Stent Grafting for Chronic Dissecting Aortic Aneurysm with Aberrant Right Subclavian Artery:Report of a Case].

A 59-year-old man was referred to our hospital for surgery for a dissecting aortic aneurysm with an aberrant right subclavian artery( ARSA). He had a history of surgery for atrial septal defect at the age of 3 and developed Stanford type B aortic dissection at the age of 53. The maximum diameter of the aortic aneurysm was 68 mm, and the entry was located close to the ARSA origin. We established cardiopulmonary bypass using the femoral artery and vein and performed a median re-sternotomy. We performed total arch replacement with the open stent-grafting technique. The ARSA was ligated from the right thoracic cavity. Three arch branches were reconstructed in situ, and the right axillary artery was bypassed with a 9 mm Dacron graft. Six months after that operation, reduction of the false lumen was observed. This strategy is considered to be effective for chronic aortic dissection with ARSA.

Ex-vivo aortic root and coronary artery cast measurement to validate the accuracy of virtual imaging.

BACKGROUND AND AIM OF THE STUDY: To investigate the accuracy of two methods of measuring features in cardiac anatomy, using an objective standard cast model. METHODS: We made a silicone cast using a swine heart. Computerized tomography data of the solidified cast were processed through virtual reality (VR) software and through two-dimensional multiplanar-reconstruction (2D-MPR), and all measurements were compared against physical measurements of the cast. RESULTS: The cast perfectly demonstrated the fine detail of the aortic valve and the proximal parts of coronary arteries. Anatomical features were measured by 3D-VR, 2D-MPR, and directly on the cast. Measurement differences between 2D-MPR and the cast were on average at least 3.6 times larger than those between 3D-VR and the cast. CONCLUSIONS: Based on the observed accuracy, 3D-VR measurements seem considerably more accurate than the current standard 2D-MPR, and 3D-VR may be considered as the next gold standard for 3D measurement of cardiac anatomy in vivo.

[A Novel Virtual-reality Imaging System in Cardiovascular Surgery:a Potentially Promising Technology for Surgeons].

Adequate preoperative planning may facilitate successful procedures in cardiovascular surgery. We have developed a system named the Vesalius 3D suite, combining three-dimensional (3D) image-processing software with an optic-tracking spatial navigation, allowing quick, accessible 3D image interpretation for virtual reality (VR) exploration and measurement from one or more of a range of imaging modalities. We present a novel method of virtual imaging analysis for preoperative planning and simulation in cardiovascular surgery using this 3D-VR system. Based on unimodal or multimodal medical imaging data, digital imaging and communication in medicine (DICOM) data sets can be reconstructed for 3D visualization. Virtually reconstructed images can be viewed on flat-screen or stereoscopic display, revealing each patient's specific anatomy and the internal structures in exquisite detail. Highly accessible 3D interpretation promptly permits precise measurements of repair-relevant anatomical parameters including geometrically complex shapes. This technology may promote understanding of form and function in the cardiovascular system, and facilitate operative procedures in more challenging cases, and it seems especially valuable for any surgeon to gain experience in practicing for rarely-performed procedures or uncommon patient-specific preoperative surgical rehearsal.

[Dual Repair for Ischemic/Functional Mitral Regurgitation].

In the era of M-clip, surgery for ischemic/functional mitral regurgitation( FMR) which is a ventricular disease remains a challenge. We try to do ventricular treatment as much as possible. We reviewed 11 patients( 9 males, 63±12 years old) who had "dual repair" surgery which consists of anterior relocation of both papillary heads/muscles and simplified ventricular restoration (frozen-apex restoration). There was 1 hospital death of mesenteric ischemia in a 80 years old patient with sarcoidosis and chronic kidney disease(CKD). FMR changed from 2.7±0.9 preoperatively to 0.9±0.5( p<0.001) postoperatively. Similarly, New York Heart Association (NYHA) class from 3.7±0.8 to 1.8±0.6 (p<0.001), left ventricular end-diastolic dimension (LVDd) from 72±12 to 67±12 mm (p<0.01), end-systolic dimension (Ds) from 65±12 to 59±14 mm (p<0.01), ejection fraction (EF) from 23±8 to 28±10 (p=0.04), and right ventricular pressure( RVP) from 38±13 to 31±8 mmHg. There was no late death with the follow-up of 20±15 months (range 2∼42 months). In conclusion, ventricular treatment by "dual repair" surgery helps patients with FMR. Surgery may be a good compensatory treatment for catheter intervention.

[Usefulness of Balloon Aortic Valvuloplasty for Determining the Operative Procedure in a Patient with Severe Aortic Stenosis Complicated with Secondary Mitral Regurgitation;Report of a Case].

A 59-year-old man on chronic hemodialysis presented with severe aortic stenosis(AS) and moderate mitral regurgitation (MR). Although aortic valve replacement was scheduled, his status deteriorated into New York Heart Association(NYHA) class III heart failure due to the exacerbation of AS and concomitant MR. Double valve replacement was considered to be too high risk for the patient, and balloon aortic valvuloplasty(BAV) was initially performed. As a result, the mean pressure gradient of the aortic valve decreased from 65 to 28 mmHg and the mean pulmonary pressure also from 52 to 33 mmHg. Furthermore, MR improved from severe to moderate following BAV. We considered the alleviation of aortic stenosis was sufficient treatment for the patient. He underwent aortic valve replacement on the following day of BAV. Postoperative echocardiogram after 1 month showed mild MR, and the estimated pulmonary systolic pressure was 35 mmHg. During the 1-year follow up, MR was not aggravated. BAV might be a useful diagnostic method to determine the operative strategy for severe AS complicated with secondary MR.

Moderate hypothermia circulatory arrest as a brain-protective strategy for type A aortic dissection.

OBJECTIVES: Brain-protective strategies for acute type A aortic dissection (TAAD) remain controversial. Moderate hypothermia circulatory arrest (MHCA) without cerebral perfusion is not commonly used. However, we aimed to assess its safety and efficacy in 358 patients who underwent hemiarch replacement with MHCA for acute type A aortic dissection at our institution from August 2012 to August 2022. METHODS: Clinical outcomes were compared according to circulatory arrest time [≤15 min (S group, n = 52) vs ≥16 min (L group, n = 306)]. The primary outcome was postoperative stroke. RESULTS: The S group had more older patients (72.5 vs 68.8 years; P = 0.04), a greater incidence of carotid artery malperfusion (21% vs 11%; P = 0.043) and a lower body mass index (21.7 vs 23.6 kg/m2; P < 0.01) and hemodynamic instability (3.8% vs 16%; P = 0.02) than the L group. The incidence of postoperative stroke (7.7% vs 12%; P = 0.33) and the rate of 30-day mortality (5.8% vs 6.5%; P = 0.83) did not significantly differ between groups. After adjusting for all potential confounding factors pre- and intraoperatively, there was no significant difference in postoperative outcomes between groups. CONCLUSIONS: MHCA alone for TAAD had comparable postoperative outcomes with circulatory arrest times under and over 15 min. However, longer arrest times were associated with a higher risk of stroke.

Surgical repair for primary tricuspid regurgitation related to trauma.

We report a case of a 45-year-old man presenting with tachycardia and palpitation. Echocardiography indicated severe tricuspid regurgitation. We suspected traumatic tricuspid damage due to high energy trauma in a motor vehicle accident 17 years earlier. He underwent a sternotomy, and his tricuspid valve was repaired with chordal reconstruction, indentation closure, and ring annuloplasty. The postoperative period was uneventful, and he was discharged 10 days after the operation. This report highlights the value of echocardiography for diagnosis of primary tricuspid regurgitation related to trauma, and the importance of early diagnosis to allow surgical intervention before irreversible damage occurs. Learning objective: Traumatic tricuspid regurgitation is a rare cardiovascular complication of blunt chest trauma. The mechanism of the tricuspid valve injury is thought to be secondary to sudden impact causing an anteroposterior compression of the right ventricle by the sternum in end-diastole. This injury is often incidentally identified or can be missed until the patient experiences symptoms of right heart failure resulting from severe tricuspid regurgitation.

Persistent Left Superior Vena cava with the Absence of the Right Superior Vena Cava and Atrial Appendage: Complex Pacemaker Implantation in a Patient Presenting with a Rare Vascular Anomaly.

A persistent left superior vena cava (PLSVC) is a commonly observed anatomical anomaly that is frequently detected incidentally via computed tomography (CT) imaging. However, the occurrence of a PLSVC with a right superior vena cava (RSVC) defect, also known as "isolated PLSVC," is a much rarer anomaly. This peculiar malformation can lead to sinoatrial dysfunction, thus necessitating pacemaker implantation, which requires delicate manipulation due to various anatomical complexities. We herein present a case of a sick sinus syndrome with this rare anomaly, which required special consideration when performing pacemaker lead placement.

Validation of Virtual Imaging of a Dynamic, Functioning Aortic Valve Using an Ex Vivo Porcine Heart.

PURPOSE: To investigate a virtual reality imaging system in terms of visualization accuracy and appropriate orientation when displaying cardiac anatomy, we used an ex vivo model enabling direct comparison between reconstructed 3-dimensional visualization of intracardiac structures and real-time visual images. DESCRIPTION: We established a systole-diastole platform using a swine heart activated by an external mechanical pump and reservoir, allowing simultaneous acquisition of endoscopic visual and computed tomography images of the aortic valve. Virtual images were processed from computed tomography data using 3-dimensional software (the Vesalius 3D suite; PS Medtech, Amsterdam, Netherlands) and compared with visual images seen through a fiberoptic scope. EVALUATION: An endoscope gave a fine view of the aortic valve, whereas the virtual images elucidated the valve structures. Superimposition of the images from the 2 different modalities showed the virtual reality images precisely matching the visual images in both systole and diastole, confirming the validity of this virtual reality application. CONCLUSION: In view of this demonstrated fidelity of virtual imaging, this technology may be of sufficiently high quality to be considered a gold standard for cardiac anatomy.

A Virtual-Reality Imaging Analysis of the Dynamic Aortic Root Anatomy.

PURPOSE: To measure and explore complex cardiac anatomy in research and preoperative simulation, a virtual imaging technology-the Vesalius 3D suite (PS Medtech, Amsterdam, Netherlands)-combines Vesalius three-dimensional (3D) image-processing software with an optic-tracking navigation system running PST-Client software. We present a novel method of evaluating dynamic aortic root geometry in vivo using this visualization system. DESCRIPTION: Based on electrocardiography-gated cardiac computed tomography data in systole and diastole, images of the aortic root in a healthy adult were reconstructed for 3D visualization. Virtual interaction tools were used to explore and measure the aortic root structures. EVALUATION: Virtually reconstructed images revealed the aortic root internal structures in exquisite detail. Highly accessible 3D interpretation promptly permitted precise measurements of repair-relevant anatomic parameters, including geometrically complex curves of the aortic root wall and dynamic changes in the aortic valves. Measurement accuracy examined against a known prosthesis showed within 1 mm of error (less than 0.5%). CONCLUSIONS: This technology may promote understanding of aortic root form and function, and facilitate valve-sparing surgery, and seems valuable for 3D exploration and measurement of cardiac anatomy in vivo.

High-dose chemotherapy with autologous stem cell transplantation following systemic chemotherapy, prophylactic intrathecal methotrexate, and radiotherapy prevents relapse and improves the outcome of advanced stage primary testicular lymphoma even with cardiac involvement.

Primary testicular lymphoma (PTL) is a rare but aggressive disease. Although most patients present in the early stage, their prognosis is poor. Similar with PTL, cardiac lymphoma is also an uncommon disease characterized by its aggressive clinical course and poor prognosis. We herein report an extremely rare case of advanced stage PTL with cardiac involvement, treated by high-dose chemotherapy with autologous stem cell transplantation (HDT-ASCT) followed by systemic chemotherapy, prophylactic intrathecal methotrexate (IT-MTX), and radiotherapy. A 48-year-old man presented with painless left scrotal swelling. He was diagnosed with PTL after orchiectomy, and the histological type was diffuse large B-cell lymphoma. For staging of lymphoma, positron emission tomography was performed, which revealed uptake in the right atrium and early cardiac metastasis within just 2 months after orchiectomy. He underwent 6 cycles of systemic chemotherapy that consisted of rituximab, doxorubicin, cyclophosphamide, vincristine, and prednisolone (R-CHOP). He also received central nervous system prophylaxis 4 times with weekly IT-MTX during the first 2 cycles of R-CHOP. He achieved complete response after 6 cycles of R-CHOP, and underwent HDT-ASCT and radiotherapy as consolidation therapy without irreversible adverse effects. He is currently doing well, with a progression-free survival of 31 months. The above treatment strategy including HDT-ASCT may be one of the treatment options for advanced stage PTL with cardiac metastasis in patients younger than 65 years old.

Achievement of the longest survival of paraneoplastic pemphigus with bronchiolitis obliterans associated with follicular lymphoma using R-CHOP chemotherapy.

Paraneoplastic pemphigus (PNP) is a rare, fatal, paraneoplastic autoimmune mucocutaneous blistering disease, commonly associated with lymphoproliferative disorders, including malignant lymphomas. Lymphoproliferative disorders associated with PNP are sometimes associated with a serious lung complication, bronchiolitis obliterans (BO). Due to its rarity, guidelines for the management of PNP have not been established. Furthermore, most patients die within 1 year. Here we report the successful treatment of lymphoma-associated PNP and BO using R-CHOP chemotherapy. A 53-year-old Japanese man was admitted to our hospital for severe erosive stomatitis. Computed tomography and positron emission tomography showed multiple lymphadenopathies. He was diagnosed with follicular lymphoma (Ann Arbor stage IVA) and PNP-related BO. The patient underwent six cycles of R-CHOP and an additional cycle of rituximab. Both the erosive stomatitis and the obstructive lung disease persisted, but complete response of the follicular lymphoma was achieved. The patient survived 27 months after diagnosis. Although he died from progressive respiratory failure due to BO, we note that this patient achieved the longest survival of any reported case of PNP-related BO associated with a lymphoproliferative disorder. The present case suggests that intensive immunochemotherapy for underlying lymphoma may improve the prognosis in patients with PNP-related BO associated with lymphoma.

Transgenic Drosophila models of Noonan syndrome causing PTPN11 gain-of-function mutations.

Mutations in the PTPN11 gene, which encodes the protein tyrosine phosphatase SHP-2, causes Noonan syndrome (NS), an autosomal dominant disorder with pleomorphic developmental abnormalities. Certain germline and somatic PTPN11 mutations cause leukemias. Mutations have gain-of-function (GOF) effects with the commonest NS allele, N308D, being weaker than the leukemia-causing mutations. To study the effects of disease-associated PTPN11 alleles, we generated transgenic fruitflies with GAL4-inducible expression of wild-type or mutant csw, the Drosophila orthologue of PTPN11. All three transgenic mutant CSWs rescued a hypomorphic csw allele's eye phenotype, documenting activity. Ubiquitous expression of two strong csw mutant alleles were lethal, but did not perturb development from some CSW-dependent receptor tyrosine kinase pathways. Ubiquitous expression of the weaker N308D allele caused ectopic wing veins, identical to the EGFR GOF phenotype. Epistatic analyses established that csw(N308D)'s ectopic wing vein phenotype required intact EGF ligand and receptor, and that this transgene interacted genetically with Notch, DPP and JAK/STAT signaling. Expression of the mutant csw transgenes increased RAS-MAP kinase activation, which was necessary but not sufficient for transducing their phenotypes. The findings from these fly models provided hypotheses testable in mammalian models, in which these signaling cassettes are largely conserved. In addition, these fly models can be used for sensitized screens to identify novel interacting genes as well as for high-throughput screening of therapeutic compounds for NS and PTPN11-related cancers.