Impact of sleep-disordered breathing on ventricular tachyarrhythmias after left ventricular assist device implantation.

Sleep-disordered breathing (SDB) is associated with an increased risk of adverse events in patients with heart failure (HF); however, its impact in patients implanted with a left ventricular assist device (LVAD) remains unclear. We aimed to investigate the prevalence of SDB in patients with LVAD and its impact on their clinical outcomes. Fifty consecutive patients with LVAD who underwent portable sleep monitoring between September 2017 and April 2018 were prospectively enrolled, and they were followed up for 170 ± 36 days. According to their respiratory disturbance indexes (RDIs), they were categorized into the SDB group (RDI ≥ 15, n = 12) and the non-SDB group (RDI < 15, n = 38). The incidence of adverse events during the follow-up period was investigated after enrollment. Multivariate logistic regression analysis revealed significant differences in SDB in LVAD-implanted patients in terms of the logarithmic transformation brain natriuretic peptide (BNP) values (p = 0.005). The optimal BNP cut-off value for SDB prediction in LVAD-implanted patients was 300 pg/mL (sensitivity: 58.3%, specificity: 94.7%). During follow-up, ventricular tachyarrhythmias (VTas) occurred significantly more frequently in the SDB group (4 [33%] vs. 2 [5%] patients, p = 0.02); Atrial tachyarrhythmia (ATa) also tended to occur more frequently in the SDB group (2 [25%] vs. 2 [2%] patients, p = 0.07). SBD was prevalent in 24% of the LVAD-implanted patients with advanced HF. Furthermore, SDB was significantly associated with high BNP levels and was also potentially associated with subsequent incidence of VTa in patients with LVAD.

Influence of Induction Therapy Using Basiliximab With Delayed Tacrolimus Administration in Heart Transplant Recipients　- Comparison With Standard Tacrolimus-Based Triple Immunosuppression.

BACKGROUND: Appropriate indications and protocols for induction therapy using basiliximab have not been fully established in heart transplant (HTx) recipients. This study elucidated the influence of induction therapy using basiliximab along with delayed tacrolimus (Tac) initiation on the outcomes of high-risk HTx recipients.Methods and Results:A total of 86 HTx recipients treated with Tac-based immunosuppression were retrospectively reviewed. Induction therapy was administered to 46 recipients (53.5%) with impaired renal function, pre-transplant sensitization, and recipient- and donor-related risk factors (Induction group). Tac administration was delayed in the Induction group. Induction group subjects showed a lower cumulative incidence of acute cellular rejection grade ≥1R after propensity score adjustment, but this was not significantly different (hazard ratio [HR]: 0.63, 95% confidence interval [CI]: 0.37-1.08, P=0.093). Renal dysfunction in the Induction group significantly improved 6 months post-transplantation (P=0.029). The cumulative incidence of bacterial or fungal infections was significantly higher in the Induction group (HR: 10.6, 95% CI: 1.28-88.2, P=0.029). CONCLUSIONS: These results suggest that basiliximab-based induction therapy with delayed Tac initiation may suppress mild acute cellular rejection and improve renal function in recipients with renal dysfunction, resulting in its non-inferior outcome, even in high-risk patients, when applied to the appropriate recipients. However, it should be carefully considered in recipients at a high risk of bacterial and fungal infections.

Early postoperative heparinization reduce hemolysis in patients with HeartMate II devices.

Hemolysis is closely related with pump thrombosis and thromboembolic events in patients with continuous flow left ventricular assist devices. We retrospectively investigated the impact of early postoperative heparinization on hemolysis in patients with HeartMate II devices. From April 2013 to August 2017, 83 patients (age 45 ± 12 years; 20 females; body surface area 1.6 ± 0.2 m2) underwent HeartMate II implantation. Postoperative heparinization was started when hemostasis was achieved and continued until full warfarinization. Hemolysis was defined in accordance with the Interagency Registry for Mechanically Assisted Circulatory Support definitions. The average support period was 22 ± 14 months. The 6-, 12-, and 24-month freedoms from hemolysis were 72%, 70%, and 67%, respectively. Pump thrombosis developed in five (6%) patients and four (5%) required pump exchanges. Heparin start time was significantly later in patients with hemolysis (43 ± 23 h after implantation) versus those without (29 ± 14 h after implantation; p = 0.01). Receiver operating characteristic analysis determined the cut-off point of heparin start time as 29 h. The patients were divided into the early group (heparin start time < 29 h; n = 29), and the late group (heparin start time > 29 h; n = 54). The respective 6-, 12-, and 24-month freedoms from hemolysis for the early group (86%, 86%, and 86%, respectively) were significantly higher than those for the late group (49%, 47%, and 44%, respectively; p = 0.002). Being in the late group was an independent risk factor for hemolysis (hazard ratio 4.09). Early postoperative heparinization (within 29 h after implantation) reduces hemolysis in patients with HeartMate II devices.

Role of Gallium-SPECT-CT in the Management of Patients With Ventricular Assist Device-Specific Percutaneous Driveline Infection.

BACKGROUND: Percutaneous driveline infection is a major complication of left ventricular assist device (LVAD). This study evaluated the role of gallium-67 single-photon emission computed tomography (Ga-SPECT)-CT in LVAD-specific percutaneous driveline infection. METHODS: Thirty-six patients with implantable continuous-flow LVAD, who underwent Ga-SPECT-CT to evaluate percutaneous driveline infections, were enrolled and divided into uptake and no-uptake groups based on tracer concentration uptake on Ga-SPECT-CT. Primary outcomes were surgical intervention and readmission for driveline infection. RESULTS: Twenty-two patients had uptake on Ga-SPECT-CT. No significant differences were noted in patient characteristics, wound appearance, or laboratory results. The prevalence of positive skin culture at the driveline exit site (DLES), and usage and duration of antibiotics did not differ. However, the uptake group had higher 1-year event rates (surgical intervention: 39% vs 0%, P = .019; readmission: 74% vs 6.9%, P = .0016). In addition to positive skin culture at DLES and short duration of antibiotic therapy, uptake on Ga-SPECT-CT was a risk factor for surgical intervention (odds ratio 9.00; P = .018) and readmission (odds ratio 7.86; P = .0051). CONCLUSIONS: Ga-SPECT-CT could be one of the clinical modalities for guiding the treatment of driveline infection in patients with a LVAD.

Heart Transplantation Ameliorates Ambulation Capacity in Patients With Muscular Dystrophy　- An Analysis of 9 Cases.

BACKGROUND: Heart transplantation (HTx) is reported to have a comparable effect on the prognosis of heart failure patients without muscular disease and for those with muscular dystrophy (MD). However, little is known about the changes in muscular diseases in patients with MD after HTx. Methods and Results: We assessed the ambulatory capacity of 9 patients with MD who underwent HTx. All patients demonstrated improvement in ambulation to varying degrees and 1 patient successfully climbed Mount Fuji 3.8 years after HTx. CONCLUSIONS: HTx potentially improves not only the prognosis but also the ambulatory capacity of patients with MD.

Type and Size of Implanted Bioprosthetic Valve Rather Than Intraoperative Peak Transprosthetic Valvular Velocity Predict Postoperative Midterm Prosthesis-Patient Mismatch in Patients Undergoing Surgical Aortic Valve Replacement.

OBJECTIVES: High transprosthetic valvular peak velocity (PV) is indicative of prosthesis-patient mismatch (PPM), which exacerbates mortality and morbidity after surgical aortic valve replacement (AVR). During surgical AVR, a high intraoperative PV sometimes is detected, but whether it affects mortality and morbidity is unknown. The aims of this study were to determine whether intraoperative and postoperative PV were correlated and what factors predicted postoperative PPM. DESIGN: Retrospective, observational, cohort study. SETTING: Tertiary medical center. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study comprised 556 patients who underwent AVR with a bioprosthetic valve. PV was measured intraoperatively, 1 month after surgery, and 1 year after surgery. The occurrence of PPM was defined as an effective orifice area index of less than 0.85 cm2/m2. The associations between PV values at the aforementioned 3 time points were analyzed using a multivariable nonlinear regression model. A multivariable logistic regression model was used to identify the predictors of PPM at 1 year. There was no significant association between intraoperative PV and PV at 1 month (p = 0.419) or 1 year (p = 0.115). The implanted valve type (p < 0.001) and size (p < 0.001), but not intraoperative PV (p = 0.503), were independent predictors of PPM. CONCLUSIONS: There was no significant association between intraoperative and postoperative PV values. Implanted valve type and size, but not intraoperative PV, predicted postoperative PPM.

Driveline angle is crucial for preventing driveline infection in patients with HeartMate II device.

We hypothesized that the externalizing direction of the driveline (the driveline angle) at the percutaneous exit site would influence the occurrence of driveline infection after left ventricular assist device implantation. From August 2013 to May 2017, 71 patients were implanted with a HeartMate II device in our center. The driveline angle was measured on anteroposterior radiography just after implantation. Risk factors for driveline infection were analyzed by uni- and multivariate analyses. Driveline infection developed in 10 (14%) patients during follow-up. Overall actual freedoms from driveline infection at 6, 12, and 24 months were 96%, 88%, and 86%, respectively. Overall number of driveline infection events per patient-year was 0.16. Receiver operating characteristic analysis determined the cut-off point of the driveline angle as 41°. The 6-, 12-, and 24-month actuarial freedoms from driveline infection in those with driveline angle more than 42° (84%, 74%, and 74%, respectively) were significantly lower than in those with driveline angle less than 41° (97%, 94%, and 90%, respectively; p < 0.02). The numbers of driveline infection events per patient-year were 0.16 in patients with driveline angle more than 42°, and 0.04 in patients with driveline angle less than 41°. Multivariate analysis demonstrated that driveline angle more than 42° was an independent risk factor for driveline infection (hazard ratio 4.71). Driveline angle more than 42° is an independent risk factor for driveline infection in patients with HeartMate II. Externalization of the driveline toward the horizontal direction is important to prevent driveline infection with HeartMate II.

Experience of the use of octreotide for refractory gastrointestinal bleeding in a patient with Jarvik2000® left ventricular assist device.

Gastrointestinal bleeding (GIB) is among the major complications affecting implantable continuous-flow left ventricular assist device (iLVAD) recipients and is the major cause of re-hospitalization. GIB in iLVAD recipients is sometimes critical, and controlling bleeding using conventional approaches is difficult. A 35-year-old woman developed refractory GIB from multiple gastric polyps and de novo angiodysplasia after Jarvik2000® iLVAD implantation. Discontinuation of anticoagulation and antiplatelet therapies had little effect on GIB; thus, multiple endoscopic hemostatic therapies were performed. However, bleeding recurred several times, and red blood cell (RBC) transfusion in large volumes was required for progressive anemia. Furthermore, the von Willebrand factor (VWF) multimer analysis revealed loss of the high-molecular weight multimer, which may have resulted from the high-speed rotation of the axial-flow LVAD pump. To supplement VWF, cryoprecipitate was administered, but it was effective for only several days. Finally, the patient was treated with octreotide, a somatostatin analog, on post-operative day 58. After starting octreotide, tarry stool gradually decreased, and progression of anemia slowed down within the first 14 days of treatment; thus, the total RBC transfusion volume was reduced without additional hemostatic interventions, including cryoprecipitate administration. The patient developed mediastinitis on post-operative day 68 and died of sepsis on post-operative day 72. There was no adverse effect associated with octreotide use. Although the observation period was short, octreotide appears to be useful for resolving recurrent GIB after iLVAD implantation and reducing blood transfusions.

Benefit and Risk of Minimally Invasive Mitral Valve Repair for Type II Dysfunction　- Propensity Score-Matched Comparison.

BACKGROUND: Despite the cosmetic benefits of the minimally invasive approach for mitral disease, the clinical benefit and risk are not fully known. We investigated the benefit and risk of minimally invasive mitral valve (MV) repair for type II dysfunction using propensity score-matched analysis. Methods and Results: Since 2001, 602 patients have undergone MV repair for type II dysfunction (464 with conventional median sternotomy and 138 with the minimally invasive approach). One-to-one matched analysis using the estimated propensity score based on 23 factors resulted in 93 well-matched patient pairs. There was no in-hospital death in both groups. The operation time was significantly shorter (P=0.002), blood transfusion was less frequent (P=0.04), extubation at the day of surgery was more frequently performed (P=0.017), and the length of hospital stay was significantly shorter in the minimally invasive group than in the sternotomy group (P<0.0001). On postoperative (P=0.02) and 1-year echocardiography (P=0.04), ejection fraction was lower in the minimally invasive group than in the sternotomy group. There were no significant differences in postoperative cerebral infarction, aortic dissection, deep sternal infection, or mid-term outcome between the groups. CONCLUSIONS: Standard sternotomy and the minimally invasive approach provide similar good quality of MV repair for type II dysfunction. The minimally invasive approach is more likely to contribute to fast-track perioperative treatment than the standard sternotomy approach.

Trifecta vs. Magna for Aortic Valve Replacement　- Differences in Clinical Outcome and Valve Hemodynamics.

BACKGROUND: The number of surgical aortic valve replacements using bioprosthetic valves is increasing, and newer bioprosthetic valves may offer clinical advantages in Japanese patients, who generally require smaller replacement valves than Western patients. In this study we retrospectively evaluated the Trifecta and Magna valves to compare clinical outcomes and hemodynamics in a group of Japanese patients. Methods and Results: Data were retrospectively collected for 103 patients receiving a Trifecta valve and 356 patients receiving a Magna valve between June 2008 and 2017. Adverse events, outcomes, and valve hemodynamics were evaluated. There were no significant differences in early or late outcomes between the Trifecta and Magna groups. In the early postoperative period, mean (±SD) pressure gradient (9.0±3.1 vs. 13.8±4.8 mmHg; P<0.01) and effective orifice area (1.68±0.46 vs. 1.46±0.40 m2; P<0.01) were significantly better for Trifecta, but the differences decreased over time. In particular, the interaction between time and valve type (Trifecta or Magna) was significantly different for mean pressure gradient between the 2 groups (P<0.01). Left ventricular mass regressed substantially in both groups, with no significant difference between them. There were no significant differences for severe patient-prosthesis mismatch. CONCLUSIONS: Postoperative outcomes were similar for both valves. An early hemodynamic advantage for the Trifecta valve lasted to approximately 1 year postoperatively but did not persist.

Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis Complicated by Sigmoid Septum.

BACKGROUND: In patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS), a sigmoid septum, characterized by subaortic interventricular hypertrophy, often results in the need for new pacemaker implantation (PMI). In this study, we reviewed the feasibility and treatment efficacy of TAVR for AS in patients with a sigmoid septum. Methods and Results: Between 2011 and 2016, 48 patients (25.4%; mean age 84.9±5.4 years; 9 males) with a sigmoid septum and 141 (74.6%; mean age 82.9±5.5 years; 61 males) without underwent TAVR. Their operative outcomes, echocardiographic and electrocardiographic findings, and long-term outcomes were retrospectively compared. Second TAVR because of valve malposition was performed in 3 patients with a sigmoid septum (6.3%) and in 2 patients without a sigmoid septum (1.4%), with no significant difference between the 2 groups. Although there was no significant difference in valve hemodynamics between the 2 groups, sigmoid septum and deep implantation (implantation depth ≥10 mm) were independent predictors of new PMI following TAVR. CONCLUSIONS: Although a sigmoid septum did not preclude the feasibility, safety, or efficacy of TAVR for severe AS, its presence was associated with new PMI. Our approach to TAVR in patients with a sigmoid septum may contribute to clinical outcomes comparable to those of patients without this pathology.

Impact of Coronary Artery Calcification in the Donor Heart on Transmitted Coronary Artery Disease in Heart Transplant Recipients.

BACKGROUND: Coronary artery disease (CAD) after heart transplantation (HTx) develops as a combination of donor-transmitted coronary atherosclerosis (DTCA) and cardiac allograft vasculopathy. Assessing donor CAD before procurement is important. Because coronary artery calcification (CAC) is a predictor for CAD, donor-heart CAC is usually evaluated to estimate the risk of donor CAD. The usefulness of CAC for predicting DTCA, however, is not known. Methods and Results: Sixty-four HTx recipients whose donor underwent chest computed tomography before procurement or ≤2 weeks after HTx and who underwent coronary angiography and intravascular ultrasound (IVUS) ≤3 months after HTx were enrolled. Eight patients had CAC (CAC group) and 56 patients did not have CAC (no-CAC group). Patients in the CAC group were significantly older and had a higher prevalence of maximum intimal thickness (MIT) of the coronary artery ≥0.5 mm at initial IVUS than patients in the no-CAC group (100% vs. 55%, P=0.02). Adverse cardiac events and death were not significantly different. Everolimus tended to be used more often in the CAC group. CONCLUSIONS: Donor-heart CAC is a significant predictor for MIT of the coronary artery ≥0.5 mm after HTx. The presence of CAC, however, is not associated with future cardiac events. The higher prevalence of everolimus use in the CAC group may have affected the results.

Efficacy of regional saturation of oxygen monitor using near-infrared spectroscopy for lower limb ischemia during minimally invasive cardiac surgery.

Lower limb ischemia with an occlusive cannula is a potential complication of minimally invasive cardiac surgery (MICS). We evaluated intraoperative local oxygen supply-demand balance by monitoring regional saturation of oxygen (rSO2) using near-infrared spectroscopy (NIRS), and analyzed the correlation between cannula size and fluctuation range of rSO2. Fifty-four patients undergoing MICS surgery using femoral artery cannulation from April 2015 to August 2016 were enrolled. The rSO2 of both the cannulated and uncannulated lower limbs were measured using NIRS. The association between the decline of rSO2 from baseline (delta-rSO2) and the ratio of the cannula diameter to the femoral artery diameter (Cd/FAd) was analyzed. Of the 54 patients, 16 (30%) (Group 1) showed values over 0.65 for Cd/FAd, and the remaining 38 (70%) (Group 2) showed values under 0.65. No patient developed postoperative lower limb ischemia. No patient was treated with an ipsilateral distal perfusion cannula. There were significant differences between Group 1 and Group 2 in the decrease of rSO2 at the point of cannulation on the cannulated limb. In the lower limb on the cannulated side, delta-rSO2 showed a significant decrease in Group 1 compared to Group 2 (Group 1 vs Group 2: 19.9 vs 11.0%; p < 0.001). Delta-rSO2 was significantly correlated with body surface aera (BSA), but not with gender or age. Decreasing rSO2 correlates with the Cd/FAd index. Low BSA, Cd/Fad > 0.65 is considered as the risk factor for decline of rSO2 in cannulated limb in MICS.

Impact of mitral valve intervention with left ventricular assist device implantation on postoperative outcomes and morphologic change.

Although mitral regurgitation (MR) is prevalent in patients with end-stage heart failure, the impact of mitral valve (MV) surgery on outcomes after left ventricular assist device (LVAD) implantation and morphologic changes of MV remains unclear. We retrospectively reviewed 74 patients who underwent LVAD implantation as a bridge to transplant. Of these, 11 (15%) underwent MV repair concomitant with or prior to LVAD implantation, while 27 patients with preoperative significant (moderate or greater) MR did not undergo concomitant MV surgery. The mean interval between LVAD implantation and the last echocardiographic examination was 913 days. Irrespective of MV surgery, significant LV reverse remodeling including decreased LV and left atrial dimension and improved MR severity was observed in all patients except for patients with prior MV surgery. Histopathological examination of explanted hearts removed at heart transplantation (n = 69) or autopsy (n = 5) revealed that the MV annulus was still dilated (mean perimeter 11.7 cm) in the patients with preoperative significant MR and no concomitant MV surgery. Concomitant MV surgery at the time of LVAD implantation for significant MR might not be always necessary for bridge to transplant or destination therapy cases. However, it might be required in patients having potential for cardiac recovery or patients with severe pulmonary hypertension and depressed right ventricle.

[Outpatient Care for Implantable Left Ventricular Assist Device Patients].

From 2005, 124 patients have received implantable left ventricular assist device (iVAD) in our institute, including HeartMate II (84), EVAHEART (17), Jarvik2000 (13), DuraHeart (9), HVAD (1). At February 2018, 60 patients were waiting for heart transplant with iVAD support. Multi-specialist team consisted of clinical engineer, VAD management specialist, nurse, transplant coordinator for recipient and physicians provide patients care. Thirty one percents returned to their social activity after iVAD implantation. 73% patients required rehospitalization for more than 1 time. Overall frequency of rehospitalization was 1.43 events per patient-year. Driveline infection was the most frequent reason and tended to repeat, accounted for 41% of overall rehospitalization. To reduce skin trouble around the driveline exit site causing driveline infection, we made a skin care outpatient clinic, cooperating with a certified nurse in wound, ostomy, and continence nursing (WOC). Besides, we utilize smartphones for remote advising system for patients to facilitate early diagnosis and precise care for driveline infection. A self-anticoagulation management device( Coag-check XS personal) enable us to give adequate anticoagulation therapy and to minimize bleeding and thromboembolic event. Additionally, establishment of psychosocial care promote patient's recovery of social status. With those strategies in outpatient care, we are trying to achieve successful quality of life of iVAD patients.

Reducing Prosthesis-Patient Mismatch With Edwards Magna Prosthesis for Aortic Valve Replacement.

BACKGROUND: Prosthesis-patient mismatch (PPM) is associated with increased mid-term and long-term mortality rates after aortic valve replacement (AVR). This study aimed to evaluate the efficacy of the Carpentier-Edwards Perimount Magna and Magna Ease (CEPMs) aortic bioprostheses to reduce the incidence of PPM.Methods and Results:Altogether, 282 consecutive patients (113 women, mean age 69.9±9.9 years) underwent AVR with a CEPMs between 2008 and 2015. They were divided into 3 groups based on the risk of PPM as a result of their body surface area and aortic annular diameter (BSA/AnnD ratio): low-risk (LR) group: 0.64±0.05 m2/cm (n=94); medium-risk (MR) group: 0.73±0.02 m2/cm (n=94); high-risk (HR) group: 0.83±0.05 m2/cm (n=94). The 30-day mortality rate was 0.4%. The 5-year actuarial survival rates were 93.2%, 92.3%, and 94.8% for groups LR, MR, and HR, respectively. No explants as a result of structural valve deterioration occurred. No patients showed severe PPM, defined as a measured effective orifice area index (EOAI) <0.65 cm2/m2. Although there were significant (P<0.05) differences in EOAI (0.98±0.2, 0.90±0.21, and 0.88±0.1 cm2/m2among the LR, MR, and HR groups, respectively), the corresponding transvalvular mean pressure gradients (13.0±5.5, 12.3±4.0, 12.7±5.3 mmHg) and regression rates of the left ventricular mass (29.8%, 28.7%, 28.9%) were similar among groups. CONCLUSIONS: CEPMs provide low surgical risk and reduce the risks of PPM, even in HR patients, with excellent hemodynamics.

Long-Term Outcomes of Suture vs. Ring Tricuspid Annuloplasty for Functional Tricuspid Regurgitation.

BACKGROUND: Whether there is a significant difference in the long-term surgical outcomes between suture annuloplasty and ring annuloplasty for the treatment of functional tricuspid regurgitation (TR) is still controversial. We compared the long-term outcomes of tricuspid annuloplasty (TAP) with and without an annuloplasty ring.Methods and Results:From January 1996 to December 2015, we consecutively enrolled 684 patients (mean age, 65.5 years; 60% women) undergoing TAP for functional TR: 312 underwent conventional suture annuloplasty (Group S) and 372 underwent ring annuloplasty (Group R). Baseline characteristics were comparable between the 2 groups, except for age and the prevalence of prior cardiac surgery. The mean follow-up period was 7.3 years (range, 0.3-20.3 years).There was no significant difference in overall survival, freedom from major adverse cardiac and cerebrovascular events, and freedom from recurrent moderate to severe TR between Groups S and R, although postoperative mean TR grade and sPAP were significantly lower in Group R. Multivariate analysis revealed that age, prior cardiac surgery, and preoperative severe TR were independent predictors of recurrent moderate or greater TR. CONCLUSIONS: There was no significant difference in the long-term surgical outcomes between ring and suture TAP, although postoperative mean TR grade was lower in the ring annuloplasty group.

Transcatheter Aortic Valve Implantation for Degenerated 19-mm Aortic Bioprosthetic Valve.

BACKGROUND: The valve-in-valve procedure, in which a transcatheter heart valve (THV) is implanted over a prosthetic valve, has been shown to be safe and therapeutically effective, depending on the size of the replacement valve.Methods and Results:We report 3 cases of successful valve-in-valve procedure to replace a degenerated 19-mm stented prosthetic aortic valve. Balloon-expanding THVs were implanted: 20-mm in the 1st case and 23-mm in the next 2. Aortic stenosis was almost completely resolved in all patients, who recovered promptly and without cardiac adverse events. CONCLUSIONS: Using the valve-in-valve procedure for a 19-mm degenerated bioprosthesis was feasible and safe.

889 days of support on hydrodynamic bearing rotation mode of the DuraHeart™ for bridge-to-heart transplantation.

A 49-year-old man with ischemic cardiomyopathy and tricuspid regurgitation underwent a DuraHeart implantation and tricuspid annuloplasty for bridge-to-heart transplantation. On postoperative day 393, the magnetic levitation system suddenly broke down, and the pump system went into hydrodynamic bearing rotation (HD) mode without causing relevant symptoms. The controller was exchanged with one that adapted to the HD mode. No significant hemodynamic changes or indications of hemolysis were observed. On postoperative day 982, the pump temporarily stopped nine times. The patient refused pump exchange despite our strong recommendation for it. After 1283 days of DuraHeart support (889 days in HD mode) without hemolysis or neurologic events, he underwent heart transplantation. The DuraHeart manufacturer's analysis revealed much damage to the insulation and fatigue fractures of the conductors, which had resulted in temporary cessation of function and failure of the magnetic levitation system. This was a rare case of long-term support under the DuraHeart HD mode.

Hemodynamic Performance and Durability of Mosaic Bioprostheses for Aortic Valve Replacement, up to 13 Years.

BACKGROUND: This study evaluated the mid to long-term durability and hemodynamics of the small-size Mosaic bioprosthesis, a third-generation stented porcine bioprosthesis, for aortic valve replacement (AVR). METHODS AND RESULTS: From 2000 to 2012, 207 patients (117 women; age, 74±8 years; body surface area, 1.48±0.25 m(2)) underwent AVR with a Mosaic bioprosthesis. The mean follow-up period was 3.5±2.7 years (maximum, 12.4 years) and the follow-up rate was 93.7%. A 19-, 21-, 23-, 25-, and 27-mm prosthesis was used in 103, 53, 35, 13, and 3 patients, respectively. The measured effective orifice area was 1.17±0.25, 1.29±0.19, 1.39±0.24, and 1.69 cm(2)for the 19-25 mm prostheses, and the mean transvalvular pressure gradient was 19.4±6.0, 18.5±5.8, 16.5±7.3, and 13.2±2.9 mmHg, respectively. The left ventricular mass regression was significant (P<0.05) with rates of 74.6±18.8%, 75.5±30.2%, 68.1±30.5%, 55.9±12.9%, and 49.2%, respectively. The 30-day mortality rate was 1.9% and the 5- and 10-year actuarial survival rates were 86.0% and 73.7%, respectively. Valve-related comorbidities occurred in 3 patients (structural valve deterioration [SVD] in 1 after 7.2 years, and prosthetic valve endocarditis in 2). Freedom from SVD at 10-year was 96.7%. CONCLUSIONS: The mid to long-term performance of the small Mosaic bioprosthesis was satisfactory, with excellent hemodynamics and few valve-related adverse events.