The outcomes of a standardized protocol for extracorporeal mechanical circulatory support selection-left ventricular challenge protocol.

There are no criteria for surgical mechanical circulatory system (MCS) selection for acute heart failure. Since 2021, we have utilized cardiopulmonary bypass system to assess patients' heart and lung condition to inform surgical MCS selection. we aimed to retrospectively analyze the outcomes of treatments administered using our protocol. We analyzed the data of 19 patients who underwent surgical MCS implantation. We compared patients' characteristics across the biventricular-assist device (BiVAD), central Y-Y extracorporeal membrane oxygenation (ECMO), central ECMO, and left VAD (LVAD) systems. Patients' diagnoses included fulminant myocarditis (47.4%), dilated cardiomyopathy (21.1%), acute myocardial infarction (15.8%), infarction from aortic dissection (5.3%), doxorubicin-related cardiomyopathy (5.3%), and tachycardia-induced myocarditis (5.3%). Eight patients (42.1%) underwent LVAD implantation, 1 (5.2%) underwent central ECMO, 4 (21.1%) underwent BiVAD implantation, and 6 (31.6%) underwent central Y-Y ECMO. 48 h after surgery, both the pulmonary arterial and right atrial pressures were effectively controlled, with median values being 19.0 mmHg and 9.0 mmHg, respectively. No patients transitioned from LVAD to BiVAD in the delayed period. Cerebrovascular events occurred in 21.1%. Successful weaning was achieved in 11 patients (57.9%), and 5 patients (26.3%) were converted to durable LVAD. Two-year cumulative survival was 84.2%. Our protocol showed good results for device selection in patients with heart failure, and device selection according to this protocol enabled good control of the pulmonary and systemic circulations.

Use of cardiopulmonary bypass is associated with chronic postsurgical pain among patients undergoing coronary artery bypass graft surgery: follow-up of a randomized, clinical trial.

BACKGROUND: Chronic postsurgical pain (CPSP) worsens patients' mortality, morbidity, and quality of life. Cardiopulmonary bypass is mandatory for cardiac surgery, but it induces intense inflammation. The presence of inflammation is a crucial part of pain sensitization. An extreme inflammatory response due to cardiopulmonary bypass might cause a high prevalence of CPSP after cardiac surgery. We hypothesized that the prevalence and severity of CPSP are higher in patients after on-pump coronary artery bypass graft (CABG) surgery than in those after off-pump CABG surgery. METHODS: This prospective, observational study was performed on a cohort from a randomized trial (on-pump CABG: 81 patients, off-pump CABG: 86 patients). A questionnaire about the severity of surgical wound pain that evaluated pain with the numerical rating scale (NRS) was filled out by the patients. NRS responses for current pain, peak pain in the last 4 weeks, and average pain in the last 4 weeks were evaluated. The main outcomes were the severity of CPSP as evaluated using the NRS and the prevalence of CPSP. CPSP was defined as pain with an NRS score > 0. Differences in severity between groups were analyzed using multivariate ordinal logistic regression models adjusted for age and sex, and differences in prevalence between groups were analyzed using multivariate logistic regression models adjusted for age and sex. RESULTS: The questionnaire return rate was 77.0%. During a median follow-up of 17 years, 26 patients complained of CPSP (on-pump CABG: 20 patients, off-pump CABG: 6 patients). Ordinal logistic regression showed that the NRS response for current pain (odds ratio [OR] 2.34; 95% CI 1.12-4.92; P = 0.024) and the NRS response for peak pain in the last 4 weeks (OR 2.71; 95% CI 1.35-5.42; P = 0.005) were significantly higher in patients who underwent on-pump CABG surgery than in those who underwent off-pump CABG. Logistic regression showed that on-pump CABG surgery was an independent predictor of CPSP (OR 2.59; 95% CI 1.06-6.31; P = 0.036). CONCLUSIONS: The prevalence and severity of CPSP are higher in patients with on-pump CABG surgery than in those with off-pump CABG surgery.

Early Atrial Tachyarrhythmia Recurrence Predicts Late Atrial Tachyarrhythmia Recurrence After the Cryo-Maze Procedure　- An Observational Study.

BACKGROUND: It is unknown whether early atrial tachyarrhythmia (ATA) recurrence occurring within 3 months after the Maze procedure predicts late ATA recurrence.Methods and Results: This study involved 610 patients who underwent the modified Cryo-Maze procedure in conjunction with other cardiac surgery. The primary outcomes were late ATA recurrence, defined as occurring ≥3 months after surgery. The effects of early ATA recurrence on late ATA recurrence were analyzed using a Cox proportional hazards model. The following 11 covariates were considered explanatory variables: early ATA recurrence, age, sex, body surface area, preoperative duration of atrial fibrillation, preoperative left atrial diameter, and concomitant surgery (mitral valve replacement, mitral valve repair, aortic valve replacement, tricuspid annuloplasty, and left atrial appendage closure). Statistical analyses were performed with a 2-sided 5% significance level. Early ATA recurrence occurred in 174 patients (28.5%). Late ATA recurrence occurred in 167 patients (27.5%), with 595 events identified in these patients. The Cox proportional hazards model showed that early ATA recurrence was an independent predictor of late ATA recurrence (hazard ratio, 4.14; 95% confidence interval, 3.00-5.70; P<0.001)Conclusions: Early ATA recurrence was an independent predictor of late ATA recurrence among patients undergoing the modified Cryo-Maze procedure. The blanking period might not be applied to patients undergoing the modified Cryo-Maze procedure.

Transaortic Transcatheter Aortic Valve Replacement in Patients From a Single Institution　- Feasibility, Safety, and Midterm Outcomes.

BACKGROUND: Transaortic transcatheter aortic valve replacement (TAo-TAVR) is an alternative to peripheral or transapical TAVR. The procedural feasibility, safety, and midterm outcomes of TAo-TAVR were investigated in this study.Methods and Results:Eighty-four consecutive patients underwent TAo-TAVR from 2011 to 2021. Their median age was 83 years (interquartile range, 80-87 years). The Edwards SAPIEN and Medtronic CoreValve devices were used in 45 (53.6%) and 38 (45.2%) patients, respectively. The surgical approach was a right mini-thoracotomy in 43 patients (51.2%) and partial sternotomy in 4 patients (4.8%). The remaining 37 patients (44.0%) underwent full sternotomy because of concomitant off-pump coronary artery bypass grafting. VARC-3 device success was achieved in 77 patients (91.7%). Valve migration occurred in 3 patients (3.6%) using a first-generation CoreValve device, necessitating implantation of a second valve. No aortic annulus rupture, aortic dissection, or coronary orifice occlusion occurred. Conversion to surgery was required for 1 patient because of uncontrollable bleeding. Only 1 in-hospital death occurred. New pacemaker implantation was required in 6 patients (7.1%). Echocardiography at discharge showed no or trivial paravalvular leak (PVL) in 58 patients (69.0%), mild PVL in 23 (27.4%), and mild to moderate PVL in 2 (2.4%) patients. The 1- and 3-year incidence of cardiovascular death was 1.6% and 4.8%, respectively, with no structural valve deterioration. CONCLUSIONS: TAo-TAVR is feasible and safe with satisfactory midterm outcomes using both currently available devices.

Cardiac surgery improves the postoperative frailty score of frail patients.

BACKGROUND: Cardiac surgery in frail patients has been reported to be associated with increased mortality and morbidity but may improve functional status of frail patients. Few studies have investigated the impact of cardiac surgery on the trajectory of postoperative frailty. We hypothesized that cardiac surgery in frail patients would improve frailty postoperatively. METHOD: This study included 71 patients over 65 years old who were scheduled for cardiac surgery via sternotomy or thoracotomy. Frailty was prospectively evaluated using the Kihon Checklist (KCL) at 1 and 3 months postoperatively. Patients were divided into three groups based on the preoperative KCL score: nonfrail, prefrail, and frail. The interaction between the degree of preoperative frailty and the trajectory of postoperative KCL scores was assessed. RESULTS: The KCL score changed significantly over time (P < 0.001), and the KCL score trajectory differed significantly according to the degree of preoperative frailty (P for interaction = 0.003). In the frail group, the KCL score was significantly lower 3 months postoperatively than preoperatively (median 8, interquartile range [5, 9] versus median 9, interquartile range (9, 13), P = 0.029). CONCLUSION: The trajectory of postoperative KCL scores differed significantly depending on the degree of preoperative frailty. At 3 months after cardiac surgery, the KCL score of frail patients was significantly improved, while that in nonfrail patients was significantly deteriorated.

Association Between Sternotomy Versus Thoracotomy and the Prevalence and Severity of Chronic Postsurgical Pain After Mitral Valve Repair: An Observational Cohort Study.

OBJECTIVE: Investigate differences in the prevalence and severity of chronic postsurgical pain (CPSP) after cardiac surgery via thoracotomy versus sternotomy are not well-understood. DESIGN: An observational cohort study. SETTING: A tertiary care hospital. PARTICIPANTS: Four hundred twenty-eight patients (sternotomy: 192 patients, thoracotomy: 236 patients) who underwent mitral valve repair. INTERVENTIONS: A questionnaire about the severity of surgical wound pain evaluated with a numerical rating scale (NRS) was sent. NRS responses for current pain, peak pain in the last four weeks, and average pain in the last four weeks were evaluated. MEASUREMENTS AND MAIN RESULTS: The main outcomes were the severity of CPSP evaluated using NRS and the prevalence of CPSP. CPSP was defined as pain >0 that developed after a surgical procedure. During the median follow-up of 29 months, 79 patients complained of CPSP. (sternotomy: 15 patients, thoracotomy: 64 patients). Multivariate ordinal logistic regression showed that NRS responses for current pain (adjusted odds ratio [aOR], 3.17; 95% confidence interval [CI] 1.64-6.12; p = 0.001), peak pain in the last four weeks (aOR, 2.00; 95% CI 1.11-3.61; p = 0.021), and average pain in the last four weeks (aOR, 2.21; 95% CI 1.31-3.72; p = 0.003) were significantly higher in patients who underwent thoracotomy. Multivariate logistic regression showed that thoracotomy was an independent predictor of CPSP (aOR, 3.63; 95% CI 1.67-7.88; p = 0.001). CONCLUSIONS: The prevalence and severity of CPSP were higher among patients who underwent mitral valve repair via thoracotomy than sternotomy.

U-Shaped Association Between Intraoperative Net Fluid Balance and Risk of Postoperative Recurrent Atrial Tachyarrhythmia Among Patients Undergoing the Cryo-Maze Procedure: An Observational Study.

OBJECTIVE: The ability of perioperative fluid management to prevent postoperative recurrence of atrial tachyarrhythmia remains controversial. The aim of the present study was to assess if intraoperative net fluid balance was associated with atrial tachyarrhythmia recurrence after the Cryo-Maze procedure. DESIGN: An observational cohort study. SETTING: A tertiary care hospital from April 2007 to May 2019. PARTICIPANTS: Four hundred forty-four patients undergoing the Cryo-Maze procedure in conjunction with other cardiac surgeries. INTERVENTIONS: The Cryo-Maze procedure in conjunction with other cardiac surgeries. MEASUREMENTS AND MAIN RESULTS: The main outcome was early atrial tachyarrhythmia recurrence, consisting of atrial fibrillation, atrial flutter, or atrial tachycardia, within the first three months after surgery. Complete follow-up was achieved in 443 patients (99.8%), of them 127 (28.6%) developed early atrial tachyarrhythmia recurrence. The median intraoperative net fluid balance was 1,627 mL (interquartile range, -215 to 3,557 mL). Multivariate logistic regression showed that intraoperative net fluid balance (p = 0.001), preoperative AF duration (adjusted odds ratio, 1.40; 95% CI, 1.17-1.68; p < 0.001) and left atrial volume index (aOR, 1.61; 95% CI, 1.06-2.45; p = 0.025) were independent predictors of early atrial tachyarrhythmia recurrence. The adjusted log odds were lowest (-1.52) when net fluid balance was 1,557 mL. CONCLUSIONS: There is a significant U-shaped association between intraoperative net fluid balance and early atrial tachyarrhythmia recurrence among patients undergoing the Cryo-Maze procedure.

Correlation Between Intraventricular Pressure Difference and Indexed Flow of a Left Ventricular Assist Device.

OBJECTIVES: There is no definitive parameter for left ventricular (LV) preload in patients with a continuous-flow left ventricular assist device (LVAD). The intraventricular pressure difference (IVPD) is the maximum pressure difference between the mitral valve and LV apex during diastole; and, in past studies, the IVPD was influenced by volume loading. The authors hypothesized that IVPD in LVAD patients correlates with indexed LVAD flow and that IVPD can serve as a novel parameter of LV preload in this population. DESIGN: A single-center, retrospective, observational study. SETTING: A tertiary-care hospital from August 2019 to July 2020. PARTICIPANTS: Sixteen ramp tests for adjustment of LVAD pump speed in 14 adult patients undergoing continuous-flow LVAD implantation. INTERVENTIONS: Measurement of IVPD during ramp tests. MEASUREMENTS AND MAIN RESULTS: LVAD flow and IVPD were measured at each LVAD pump speed during the ramp test for the adjustment of LVAD pump speed after patients came off cardiopulmonary bypass during LVAD implantation. A straight, longitudinal view of the left atrium and left ventricle was obtained, and the pressure difference between the mitral valve and LV apex during diastole was measured by transesophageal echocardiography. The maximum pressure difference during diastole was recorded as IVPD. The relationship between indexed LVAD flow (LVAD flow/body surface area) and IVPD was assessed by a multivariate nonlinear regression analysis with the Huber-White sandwich estimator. IVPD correlated with indexed LVAD flow (p < 0.001). CONCLUSIONS: IVPD is a useful indicator of LV preload during LVAD implantation.

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.

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.

A retrospective observational cohort study investigating the association between acute kidney injury and all-cause mortality among patients undergoing endovascular repair of abdominal aortic aneurysms.

BACKGROUND: Acute kidney injury (AKI) has been found to be associated with short- and long-term mortality and morbidity in various clinical settings. However, it is unknown whether AKI after endovascular repair of abdominal aortic aneurysms (EVAR) is associated with postoperative mortality. METHODS: This observational study analyzed patients who underwent EVAR. The primary outcome was all-cause mortality. The outcomes of patients with and without postoperative AKI were compared using the Kaplan-Meier method and log-rank test. Factors with P < 0.05 on the univariate analysis were entered into the multivariate Cox regression model. Predictors of AKI were also determined using Cox univariate and multivariate analysis. The identified predictors of AKI were excluded from multivariate analysis for all-cause mortality because these factors could intermediate outcome. RESULTS: There were 490 eligible patients. After a follow-up of 28.3 (16.8) months [mean (standard deviation)], 62 patients (12.7%) died. AKI occurred in 59 patients (12.0%). AKI was found by the log-rank test to be associated with a significant increase of all-cause mortality (P < 0.001). Preoperative estimated glomerular filtration rate, preoperative peripheral vascular disease, and emergency surgery were found to be independent predictors of AKI and these variables were excluded from the main analysis. Multivariate analysis showed AKI [hazard ratio (HR) = 1.19, 95% confidence interval (CI) 1.01-3.60, P = 0.045] and transfusion (HR = 1.05, 95% CI 1.01-1.09, P = 0.011) were independent predictors of mortality. CONCLUSIONS: In the present study, AKI and transfusion were associated with significant increases in all-cause mortality after EVAR.

A Retrospective Examination of the Efficacy of Paravertebral Block for Patients Requiring Intraoperative High-Dose Unfractionated Heparin Administration During Thoracoabdominal Aortic Aneurysm Repair.

OBJECTIVE: Postoperative respiratory complications are serious and frequently observed among patients who undergo thoracoabdominal aortic aneurysm (TAAA) repair. Paravertebral block (PVB) can provide effective analgesia for relief of postoperative thoracotomy pain and may reduce respiratory complications. However, the impact of PVB on postoperative pain and respiratory function in patients who undergo TAAA repair requiring intraoperative high-dose heparin administration is unknown. This study examined the efficacy of PVB on postoperative pain and respiratory function after TAAA repairs. DESIGN: Retrospective, observational cohort study. SETTING: Single center in Japan. PARTICIPANTS: Fifty-eight consecutive patients who underwent TAAA repair from March 2013 to October 2014. INTERVENTIONS: Application of thoracic PVB. MEASUREMENT AND MAIN RESULTS: A total of 56 patients were analyzed. Two patients were excluded because 1 patient was dead within 24 hours after surgery and 1 patient was 9 years old. Patients with PVB were defined as group P (n = 17), and patients without PVB as group C (n = 39). There was no significant difference in baseline characteristics between the 2 groups. Both postoperative pain at rest and postoperative pain while coughing were assessed using a numeric rating scale (NRS); the incidence of reintubation and noninvasive positive-pressure ventilation (NPPV) also were compared between the 2 groups. The NRS score of postoperative pain at rest was significantly lower in group P (group P: Median 2, interquartile range 1 to 3; group C: Median 6, interquartile range 5 to 7; p = 0.000), and the NRS score of postoperative pain while coughing was significantly lower in group P (group P: Median 5, interquartile range 3.5 to 6.5; group C: Median 8, interquartile range 7 to 10; p = 0.000). Reintubation rate was significantly lower in group P (group P: 0%, group C: 23%, p = 0.045); the incidences of NPPV (group P: 12%, group C: 46%, p = 0.016) and postoperative pneumonia were significantly lower in group P (group P: 0%, group C: 28%, p = 0.024). CONCLUSIONS: PVB significantly reduced postoperative pain at rest and while coughing and significantly reduced the reintubation rate, the rate of NPPV use, and postoperative pneumonia without complications. PVB could be a safe and an effective analgesic method that reduces postoperative respiratory exacerbation in patients who undergo TAAA repair.

Anterolateral papillary muscle suction causing low flow in a COVID-19 patient without medical history: a case report of central extracorporeal life support with left ventricular apex decompression.

BACKGROUND: Left ventricular (LV) decompression is an essential strategy for improving early survival in patients with refractory cardiogenic shock. Low pump flow in patients on extracorporeal life support (ECLS) with LV apex decompression is a life-threatening issue. However, identifying the underlying causes of low flow can be challenging. CASE PRESENTATION: A 38-year-old woman with COVID-19-related fulminant myocarditis was treated with central ECLS with LV apex decompression. The pump flow in the intensive care unit (ICU) was intermittently low, and low flow alerts were frequent. The initial evaluation based on pressure monitor waveforms and transthoracic echocardiography failed to identify the underlying cause. Prompt bedside transesophageal echocardiography (TEE) revealed that the anterolateral papillary muscle was suctioned into the vent cannula of the LV apex during systole. The patient underwent a repeat sternal midline incision in the operating room, and the cannula at the LV apex was repositioned. There were no further suction events after the repositioning, and the patient was weaned from ECLS 12 days after admission to the ICU. The patient was discharged in a stable condition and without neurological deficits. CONCLUSIONS: TEE is an important diagnostic tool to identify the underlying cause of low flow flow in patients undergoing ECLS with LV apex decompression.

Amino acids to prevent cardiac surgery-associated acute kidney injury: a randomized controlled trial.

BACKGROUND: This study aimed to examine the preventive effect of amino acids on postoperative acute kidney injury (AKI). METHODS: This was single-center, patient- and assessor-blinded, randomized controlled trial. Patients who underwent aortic surgery with cardiopulmonary bypass were included. The intervention group received 60 g/day of amino acids for up to 3 days. The control group received standard care. The primary outcome was the incidence of AKI. We assessed the effect of amino acids on AKI using a Cox proportional hazards regression model. RESULTS: Sixty-six patients were randomly assigned to the control or intervention group. One patient in the control group withdrew consent after randomization. The incidence of AKI was 10 patients (30.3%) in the intervention group versus 18 patients (56.2%) in the control group (adjusted hazard ratio, 0.44; 95% confidence interval, 0.20-0.95; P = 0.04). CONCLUSIONS: This trial demonstrated a significant reduction in AKI incidence with amino acid supplementation. TRIAL REGISTRATION: jRCT, jRCTs051210154. Registered 31 December 2021, https://jrct.niph.go.jp/re/reports/detail/69916.

Incidence of and risk factors for pacemaker implantation after the modified Cryo-Maze procedure for atrial fibrillation.

OBJECTIVES: The Maze procedure is a well-established treatment for atrial fibrillation. However, it is sometimes associated with bradycardia requiring pacemaker implantation. We assessed the rates of in-hospital and late-onset pacemaker implantation after the modified Cryo-Maze procedure and explored the risk factors for pacemaker implantation. METHODS: This study enrolled a series of 751 patients who underwent the modified Cryo-Maze procedure at our institution between 2001 and 2020. Multivariable Fine-Gray regression was used to analyze the risk factors for late-onset pacemaker implantation. RESULTS: Twelve patients (1.6%) underwent in-hospital pacemaker implantation, and 55 patients (7.3%) underwent late-onset pacemaker implantation during a median follow-up of 4.5 years (interquartile range, 1.4-10.0). The most common primary indication for pacemaker implantation was sick sinus syndrome (56 patients [7.5%]), followed by complete atrioventricular block (11 patients [1.5%]). The cumulative incidence of late-onset pacemaker implantation with death as a competing risk was 2.8% at 1 year, 7.7% at 5 years, and 10.8% at 10 years. Risk factors for late-onset pacemaker implantation included a longer preoperative atrial fibrillation duration (hazard ratio, 1.14; P < .001) and an older age (hazard ratio, 1.05; P = .001). The mortality, cumulative incidence of cerebrovascular accidents, and rate of atrial fibrillation recurrence were not significantly different between patients with and without pacemaker implantation. CONCLUSIONS: Longer preoperative atrial fibrillation duration and older age are risk factors for late-onset pacemaker implantation after the modified Cryo-Maze procedure. However, the incidence of pacemaker implantation is not associated with increased morbidity or atrial fibrillation recurrence.

What Is the Optimal Mitral Valve Repair for Isolated Posterior Leaflet Prolapse to Achieve Long-Term Durability?

Background This study assessed risk factors for mitral regurgitation (MR) recurrence or functional mitral stenosis during long-term follow-up in patients undergoing mitral valve repair for isolated posterior mitral leaflet prolapse. Methods and Results We assessed a consecutive series of 511 patients who underwent primary mitral valve repair for isolated posterior leaflet prolapse between 2001 and 2021. Annuloplasty using a partial band was selected in 86.3%. The leaflet resection technique was used in 83.0%, whereas the chordal replacement without resection was used in 14.5%. Risk factors were analyzed for MR recurrence ≥grade 2 or functional mitral stenosis with mean transmitral pressure gradient ≥5 mm Hg using a multivariable Fine-Gray regression model. The 1-, 5-, and 10-year cumulative incidence of MR ≥grade 2 was 7.8%, 22.7%, and 30.1%, respectively, whereas that of mean transmitral pressure gradient ≥5 mm Hg was 8.1%, 20.6%, and 29.3%, respectively. Risk factors for MR ≥grade 2 included chordal replacement without resection (hazard ratio [HR], 2.50, P<0.001) and larger prosthesis size (HR, 1.13, P=0.023), whereas factors for functional mitral stenosis were use of a full ring (partial band versus full ring, HR, 0.53, P=0.013), smaller prosthesis size (HR, 0.74, P<0.001), and larger body surface area (HR, 3.03, P=0.045). Both MR ≥grade 2 and mean transmitral pressure gradient ≥5 mm Hg at 1 year post surgery were significantly associated with the long-term incidence of reoperation. Conclusions Leaflet resection with a large partial band may be an optimal strategy for isolated posterior mitral valve prolapse.

Outcomes and residual gap analysis after the modified cryomaze procedure performed via right minithoracotomy versus sternotomy.

Objectives: Developments in both technique and technology have enabled surgeons to perform the maze procedure via right minithoracotomy (RMT) to treat atrial fibrillation (AF). This study aimed to clarify the outcomes of the modified cryomaze procedure via the RMT approach compared with the sternotomy approach. Methods: The study cohort comprised 803 consecutive patients who underwent a modified cryomaze procedure (130 via RMT and 673 via sternotomy) for paroxysmal AF and persistent AF from January 2001 to March 2022. The Gray test was applied to compare the incidence of recurrent atrial tachyarrhythmias. Additionally, residual electrical gaps were investigated in the patients who underwent additional catheter ablation for recurrent atrial tachyarrhythmias. Results: The respective 1-, 2-, and 3-year cumulative incidences of recurrent atrial tachyarrhythmias were 13.1%, 19.5%, and 23.1% in the RMT group, and 9.3%, 10.9%, and 12.8% in the sternotomy group (Gray test P = .036). All 31 patients with recurrent atrial tachyarrhythmias underwent additional catheter ablation, comprising 14 (10.8%) in the RMT group and 17 (2.5%) in the sternotomy group. There was a significant intergroup difference in the site of residual electrical gaps; the RMT group more frequently had residual gaps in the tricuspid annulus than the sternotomy group (6.2% vs 0.4%; P < .001). Conclusions: In the modified cryomaze procedure via the RMT approach, ablation failure is more likely to occur at the tricuspid annulus, where the surgical field of view is relatively poor compared with the sternotomy approach. Therefore, surgical ablation should be performed with caution when the RMT approach is used.

15-year outcomes of the JOCRI study (JOCRIED study): a randomised comparison of off-pump and on-pump multiple arterial coronary revascularisation.

OBJECTIVE: The Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) study reported a non-significant difference in early outcomes and graft patency between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting in 2005. The JOCRIED study aimed to review the long-term outcomes of the JOCRI study participants. METHOD AND RESULTS: The JOCRIED study enrolled 123 of the JOCRI study participants completing the clinical follow-up between August 2018 and August 2020; 61 patients in the off-pump group and 62 patients in the on-pump group. The follow-up period was 13.8 ± 2.8 years. The groups were compared regarding mortality, the incidence of major adverse cardiac and cerebrovascular events and repeat revascularisation. The 15-year cumulative survival rate (off-pump vs on-pump, respectively; 77.7% vs 75.3%; p = 0.85), major adverse events-free survival rate (62.5% vs 55.6%; p = 0.27) and repeat revascularisation-free rate (84.8% vs 78.0%; p = 0.16) were not significantly different between the two groups. Revascularisation was the most common major adverse events in the JOCRIED participants. Although percutaneous coronary intervention was performed in 8 patients (13%) in the off-pump group and in 14 patients (23%) in the on-pump group (p = 0.23), no patients underwent redo coronary artery bypass grafting. CONCLUSIONS: Off-pump coronary artery bypass grafting provides comparable 15-year outcomes to on-pump coronary artery bypass grafting.

Case report: central venous catheterization via internal jugular vein with associated formation of perioperative venous thrombosis during surgery in the prone position.

An unusual case of central venous catheter (CVC)-related thrombosis during supine surgery in the prone position is presented. A 76-year-old woman was scheduled for elective surgery to repair a broken lumbar instrument. A single-lumen CVC was inserted via the right internal jugular vein. Surgery was performed in the prone position, with the patient's face directed downward in the standard median position (i.e., no rotation), but with slight forward flexion at the neck. After the surgery, the external jugular vein was dilated, and a postoperative X-ray revealed an infiltrative shadow in the right thoracic cavity. Because cervical echography showed dilated cervical veins with a "moyamoya-type" echo, possibly indicating a thrombus, contrast-enhanced computed tomography was performed, revealing a venous thrombus in the right internal jugular vein. An internal jugular venous-velocity measurement suggested that her slightly flexed neck position and her prone position during surgery may have kinked the internal jugular vein, causing engorgement with venous blood. The presence of the internal jugular venous catheter may have created thrombogenic conditions. A patient's position during surgery can reduce deep venous-flow velocity, and venous blood may stagnate, contributing greatly to thrombogenicity. We should consider a patient's position during surgery as a risk factor for thrombus formation, and a careful preoperative evaluation should be made as to which route should be chosen for CVC.