Primary Graft Dysfunction After Isolated Heart Transplantation　- Incidence, Risk Factors, and Clinical Implications Based on a Single-Center Experience.

BACKGROUND: Since the international consensus on primary graft dysfunction (PGD) following heart transplantation (HT) was reported in 2014, few clinical studies have been reported. We aimed to analyze the incidence, predictive factors, and clinical implications of PGD following the International Society of Heart and Lung Transplant criteria in a single center.Methods and Results:This study enrolled 570 consecutive adult patients undergoing isolated HT between November 1992 and December 2017. Under a new set of criteria, PGD-left ventricle (PGD-LV) occurred in 35 patients (6.1%; mild, n=1 [0.2%]; moderate, n=14 [2.5%]; severe, n=20 [3.5%]), whereas PGD-right ventricle (PGD-RV) occurred in 3 (0.5%). Multivariable analysis demonstrated that preoperative admission (odds ratio [OR] 4.20; 95% confidence interval [CI] 1.24-14.26; P=0.021), preoperative extracorporeal membrane oxygenation (OR 4.03; 95% CI 1.75-9.26; P=0.001), and prolonged total ischemic time (OR 1.09; 95% CI 1.02-1.15; P=0.006) were significant predictors of moderate to severe PGD-LV. Moderate to severe PGD-LV was an independent and significant risk factor for early death (OR 55.64; 95% CI 11.65-265.73; P<0.001), with its effects extending up to 3 months after HT. CONCLUSIONS: Moderate to severe PGD-LV, as defined by the new guidelines, is an important predictor of early mortality, with effects extending up to 3 months after HT. Efforts to reduce the occurrence of moderate to severe PGD-LV may lead to better outcomes.

Epicardial left atrial appendage clip occlusion in patients with atrial fibrillation during minimally invasive cardiac surgery.

OBJECTIVE: The left atrial appendage is a major source of stroke in patients with atrial fibrillation, and clinical benefits of left atrial appendage occlusion have been demonstrated in previous studies. Complete exclusion of the left atrial appendage has been recently available with an epicardial clipping device in the setting of minimally invasive cardiac surgery. METHODS: The study enrolled consecutive patients who received surgical left atrial appendage occlusion using an epicardial clipping device in a minimally invasive cardiac surgery setting from December 2015 to December 2018. The minimally invasive cardiac surgery included cardiac surgeries performed through a minithoracotomy. The procedural success of left atrial appendage complete exclusion was examined with cardiac computed tomography. Complete exclusion of the left atrial appendage was defined when the distance from circumflex artery to the device was less than 10 mm without contrast leakage. RESULTS: Among 108 patients (age, 58.5 ± 11.5 years; 61 female, 56.5%) who were finally enrolled in the study, postoperative cardiac computed tomography was available in 103 patients. All patients had preoperative atrial fibrillation. Of these, 88 patients (81.5%) underwent simultaneous mitral valve procedure, and 3 (2.8%) and 6 (5.6%) received stand-alone procedure of left atrial appendage clipping and primary surgical ablation, respectively. There were no early deaths or device-related complications. For the procedural success rate, complete exclusion of the left atrial appendage was achieved in 95 patients (92.2%). During a median follow-up of 19 months (interquartile range, 11.7-28.3 months), there were no thromboembolic events or device-related reoperations. CONCLUSIONS: Left atrial appendage occlusion using an epicardial clipping device during cardiac surgery can be performed successfully in a minimally invasive cardiac surgery setting in selected patients.

[Primary Malignant Peripheral Nerve Sheath Tumor of the Pulmonary Vein: A Case Report]. / íì •ë§¥ì˜ 원발성 ì• ì„± ë§ì´ˆì‹ ê²½ì´ˆì¢ : 증례 ë³´ê³ .

Primary masses rarely originate from the heart and great vessels, and a malignant peripheral nerve sheath tumor (MPNST) is extremely rare. A 76-year-old male with pleural effusion underwent contrast-enhanced computed tomography, which revealed a hypoattenuating mass involving the right pulmonary vein and left atrium. Ultrasonography showed that the mass originated from the right pulmonary vein. Surgical resection confirmed an MPNST that originated from the pulmonary vein. We report the first Korean case of a primary MPNST originating from the pulmonary vein. We have also described the radiologic findings suggestive of a pulmonary vein mass.

Pre-sewn Multi-branched Aortic Graft and 3D-Printing Guidance for Crawford Extent II or III Thoracoabdominal Aortic Aneurysm Repair.

Reconstruction of the visceral and segmental arteries is a challenging part of open surgical repair of extensive thoracoabdominal aortic aneurysm (TAAA). For more efficient reconstruction of these branching vessels, a technique of using pre-hand-sewn multi-branched aortic graft (octopod technique) has been adopted with the aid of 3D-printing-guidance in latest cases. The octopod graft has been employed for the extent II or III TAAA repair, in which the commercially available two 4-branched aortic grafts were interconnected before surgery. Since January 2017, 3D-printed-aortic model has been used to efficiently replicate the projected aorta shape fitted to patient's anatomy. From May 2015 through Oct 2019, 20 patients (median age, 40years; range, 23-65; 5 females) underwent extent II or III TAAA repair using the octopod technique with (n = 9) or without (n=11) 3D-printing-guidance. Thirteen patients (65%) were diagnosed as Marfan syndrome. Eighteen patients (90%) had undergone prior aorta repair including 4 patients (20%) undergoing redo-thoracotomy. Revascularization of segmental arteries was conducted in 19 patients (95%, median, N = 2; range, 1-4). Median pump and entire procedural times were 173.5 minutes (interquartile range [IQR], 136.8-187.8) and 441 minutes (IQR, 392.8-492.3), respectively. There was no operative mortality or stroke, however, permanent paraplegia occurred in one patient (5%). During follow-up (median 35months, range 1-56 months), all of reconstructed branched vessels remained wide patent on CT. The octopod technique for open TAAA repair showed favorable early and mid-term results with high feasibility of procedural efficiency. 3D-printing guidance is expected to improve the flow of surgical procedures especially in challenging anatomy.

3-Dimensional computed tomographic assessment predicts conduction block and paravalvular leakage after rapid-deployment aortic valve replacement.

OBJECTIVES: Complications like complete atrioventricular block (CAVB) and paravalvular leakage (PVL) following rapid deployment aortic valve (AV) replacement (RDAVR) remain unresolved. Selecting an optimal size of the valve might be important to minimize the incidence of these complications. We sought to determine the impact of prosthesis size relative to the anatomic profile of the AV on the occurrence of CAVB or PVL after RDAVR. METHODS: Preoperative computed tomographic (CT) images were evaluated in patients receiving RDAVR (INTUITY ELITE) between February 2016 and December 2019. The occurrence of CAVB requiring permanent pacemaker implantation and PVL (≥ mild) was evaluated. The relative size of implants against the cross-sectional dimensions of recipients' AV annulus and left ventricular outflow tract (LVOT) were calculated. RESULTS: Among 187 eligible patients, CAVB and PVL (≥ mild) occurred in 12 (6.4%) and 11 patients (5.9%), respectively. CAVB was associated with oversized RDAVR (RDAVR frame width minus average diameter of LVOT calculated from the cross-sectional area [ΔLVOTarea]: odds ratio, 2.05; 95% confidence interval, 1.28-3.30): this was with an area under the curve of 0.78 (P = 0.005). The projected probability of CAVB was <3% when the ΔLVOTarea was <1.3. In contrast, PVL was associated with under-sized RDAVR (RDAVR size divided by the longest diameter of AV annulus [index Annlong]: odds ratio, 0.64; 95% confidence interval, 0.51-0.79): This was with an area under curve of 0.94 (P < 0.001). CONCLUSIONS: CT parameters of the AV annulus and LVOT are highly reliable in the prediction of CAVB or PVL after RDAVR. Our data might justify CT-based sizing of prosthesis for RDAVR.

Utilizing patient-specific 3D printed guides for graft reconstruction in thoracoabdominal aortic repair.

In thoracoabdominal aortic aneurysm repair, repairing the visceral and segmental arteries is challenging. Although there is a pre-hand-sewn and multi-branched graft based on the conventional image-based technique, it has shortcomings in precisely positioning and directing the visceral and segmental arteries. Here, we introduce two new reconstruction techniques using patient-specific 3D-printed graft reconstruction guides: (1) model-based technique that presents the projected aortic graft, visualizing the main aortic body and its major branches and (2) guide-based technique in which the branching vessels in the visualization model are replaced by marking points identifiable by tactile sense. We demonstrate the effectiveness by evaluating conventional and new techniques based on accuracy, marking time requirement, reproducibility, and results of survey to surgeons on the perceived efficiency and efficacy. The graft reconstruction guides cover the segmentation, design, fabrication, post-processing, and clinical application of open surgical repair of thoracoabdominal aneurysm, and proved to be efficient for accurately reconstructing customized grafts.