A novel echocardiographic parameter considering left ventricular afterload during V-A ECMO support.

BACKGROUND: Left ventricular stroke work index (LVSWI) and cardiac power index (CPI) account for the haemodynamic load of the left ventricle and are promising prognostic values in cardiogenic shock. However, accurately and non-invasively measuring these parameters during veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is challenging and potentially biased by the extracorporeal circulation. This study aimed to investigate, in an ovine model of cardiogenic shock, whether Pressure-Strain Product (PSP), a novel speckle-tracking echocardiography parameter, (1) can correlate with pressure-volume catheter-based LVSWI and CPI, and (2) can be load-independent during the flow modification of V-A ECMO. METHODS: Nine Dorset-cross ewes (51 ± 4 kg) were included. After cardiogenic shock was induced, full support V-A ECMO (X L/min based on 60 mL/kg/min) commenced. At seven time points during 24-h observation, echocardiographic parameters as well as pressure-volume catheter-based LVSWI and CPI were simultaneously measured with X and following X-1 L/min of ECMO flow. PSP was calculated by multiplying global circumferential strain or global radial strain, and mean arterial pressure, for PSPcirc or PSPrad, respectively. RESULTS: PSPcirc showed a stronger correlation with LVSWI (correlation coefficient, CC = .360, p < .001) and CPI (CC = .283, p < .001) than other echocardiographic parameters. The predictability of PSPcirc for pressure-volume catheter-based LVSWI (AUC .82) and CPI (AUC .80) was also higher than other echocardiographic parameters. No statistically significant differences were identified between the two ECMO flow variations in PSPcirc (p = .558). CONCLUSIONS: A novel echocardiographic parameter, PSP, may non-invasively predict pressure-volume catheter-based LVSWI and CPI in a load-independent manner in a cardiogenic shock supported by V-A ECMO.

JAK2 Loss Arising From Tumor-Spread-Through-Air-Spaces (STAS) Promotes Tumor Progression by Suppressing CD8+ T Cells in Lung Adenocarcinoma: A Machine Learning Approach.

BACKGROUND: Tumor spread through air spaces (STAS) is a recently discovered risk factor for lung adenocarcinoma (LUAD). The aim of this study was to investigate specific genetic alterations and anticancer immune responses related to STAS. By using a machine learning algorithm and drug screening in lung cancer cell lines, we analyzed the effect of Janus kinase 2 (JAK2) on the survival of patients with LUAD and possible drug candidates. METHODS: This study included 566 patients with LUAD corresponding to clinicopathological and genetic data. For analyses of LUAD, we applied gene set enrichment analysis (GSEA), in silico cytometry, pathway network analysis, in vitro drug screening, and gradient boosting machine (GBM) analysis. RESULTS: The patients with STAS had a shorter survival time than those without STAS (P < 0.001). We detected gene set-related downregulation of JAK2 associated with STAS using GSEA. Low JAK2 expression was related to poor prognosis and a low CD8+ T-cell fraction. In GBM, JAK2 showed improved survival prediction performance when it was added to other parameters (T stage, N stage, lymphovascular invasion, pleural invasion, tumor size). In drug screening, mirin, CCT007093, dihydroretenone, and ABT737 suppressed the growth of lung cancer cell lines with low JAK2 expression. CONCLUSION: In LUAD, low JAK2 expression linked to the presence of STAS might serve as an unfavorable prognostic factor. A relationship between JAK2 and CD8+ T cells suggests that STAS is indirectly related to the anticancer immune response. These results may contribute to the design of future experimental research and drug development programs for LUAD with STAS.

Incidence and Mortality Rates of Thoracic Aortic Dissection in Korea - Inferred from the Nationwide Health Insurance Claims.

BACKGROUND: Aortic dissection (AD) is one of the most catastrophic diseases and is associated with high morbidity and mortality. The aim of this study is to investigate the hospital incidence and mortality rates of thoracic AD in Korea using a nationwide database. METHODS: We conducted a nationwide population-based study using the health claims data of the National Health Insurance Service in Korea. From 2005 to 2016, adult patients newly diagnosed with AD were included. All patients were divided into the following four subgroups by treatment: type A surgical repair (TASR), type B surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). The incidence rate, mortality rate, and risk factors of in-hospital mortality were evaluated. RESULTS: In total, 18,565 patients were newly diagnosed with AD (TASR, n = 4,319 [23.3%]; TBSR, n = 186 [1.0%]; TEVAR, n = 697 [3.8%]; MM, n = 13,363 [72.0%]). The overall AD incidence rate was 3.76 per 100,000 person-years and exhibited a gradual increase during the study period (3.29 to 4.82, P < 0.001). The overall in-hospital mortality rate was 10.84% and remained consistent (P = 0.57). However, the in-hospital mortality rate decreased in the TASR subgroup (18.23 to 11.27%, P = 0.046). An older age, the female sex, hypertension, and chronic kidney disease were independent risk factors for in-hospital mortality. CONCLUSION: The incidence of thoracic AD has gradually increased in Korea. The in-hospital mortality in the TASR subgroup decreased over the decade, although the overall mortality of AD patients did not change.

Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.

BACKGROUND: The clinical benefit of concomitant atrial fibrillation (AF) ablation at the time of aortic valve replacement (AVR) is uncertain. METHODS AND RESULTS: A total of 124 patients with AF who underwent AVR with (n=50) or without (n=74) a concomitant maze procedure, between 2000 and 2011, were evaluated. There were no significant differences in early postoperative outcomes. During a median clinical follow-up of 18.1 months (interquartile range: 6.9-47.8 months), 19 late deaths (15.3%) and 33 valve-related complications (26.6%) occurred, but the differences between groups were not statistically significant. Major event-free survival at 5 years was 60.9±9.9% vs. 57.0±10.3% (P=0.41). After adjustment, the maze group demonstrated similar risks for major adverse cardiac events (hazard ratio, 1.18; 95% confidence interval, 0.56-2.49; P=0.67). However, the rate of sinus rhythm restoration at 4 years was significantly higher in the maze group (80.6% vs. 3.6%, P<0.001). Left atrial dimension was smaller (46.9 vs. 50.4mm, P=0.017), and the ejection fraction was higher (60.6% vs. 58.0%, P=0.059) in the maze group. The rate of postoperative anticoagulation was also lower in the maze group (53.1% vs. 89.2%, P<0.001). CONCLUSIONS: Concomitant AF ablation in patients undergoing AVR resulted in increased sinus rhythm restoration, better echocardiographic results, and decreased anticoagulation requirement, without increasing surgical morbidity or mortality.

Prognostic Analysis of Stage I Non-Small Cell Lung Cancer Abutting Adjacent Structures on Preoperative Computed Tomography.

Background: Early non-small cell lung cancer (NSCLC) that abuts adjacent structures requires careful evaluation due to its potential impact on postoperative outcomes and prognosis. We examined stage I NSCLC with invasion into adjacent structures, focusing on the prognostic implications after curative surgical resection. Methods: We retrospectively analyzed the records of 796 patients who underwent curative surgical resection for pathologic stage IA/IB NSCLC (i.e., visceral pleural invasion only) at a single center from 2008 to 2017. Patients were classified based on tumor abutment and then reclassified by the presence of visceral pleural invasion. Clinical characteristics, pathological features, and survival rates were compared. Results: The study included 181 patients with abutting NSCLC (22.7% of all participants) and 615 with non-abutting tumors (77.3%). Those with tumor abutment exhibited higher rates of non-adenocarcinoma (26.5% vs. 9.9%, p<0.01) and visceral/lymphatic/vascular invasion (30.4%/33.1%/12.7% vs. 8.5%/22.4%/5.7%, respectively; p<0.01) compared to those without abutment. Multivariable analysis identified lymphatic invasion and male sex as risk factors for overall survival (OS) and disease-free survival (DFS) in stage I NSCLC measuring 3 cm or smaller. Age, smoking history, vascular invasion, and recurrence emerged as risk factors for OS, whereas the presence of non-pure ground-glass opacity was a risk factor for DFS. Conclusion: NSCLC lesions 3 cm or smaller that abut adjacent structures present higher rates of various risk factors than non-abutting lesions, necessitating evaluation of tumor invasion into adjacent structures and lymph node metastasis. In isolation, however, the presence of tumor abutment without visceral pleural invasion does not constitute a risk factor.

Assessment and diagnosis of right ventricular failure-retrospection and future directions.

The right ventricle (RV) has a critical role in hemodynamics and right ventricular failure (RVF) often leads to poor clinical outcome. Despite the clinical importance of RVF, its definition and recognition currently rely on patients' symptoms and signs, rather than on objective parameters from quantifying RV dimensions and function. A key challenge is the geometrical complexity of the RV, which often makes it difficult to assess RV function accurately. There are several assessment modalities currently utilized in the clinical settings. Each diagnostic investigation has both advantages and limitations according to its characteristics. The purpose of this review is to reflect on the current diagnostic tools, consider the potential technological advancements and propose how to improve the assessment of right ventricular failure. Advanced technique such as automatic evaluation with artificial intelligence and 3-dimensional assessment for the complex RV structure has a potential to improve RV assessment by increasing accuracy and reproducibility of the measurements. Further, noninvasive assessments for RV-pulmonary artery coupling and right and left ventricular interaction are also warranted to overcome the load-related limitations for the accurate evaluation of RV contractile function. Future studies to cross-validate the advanced technologies in various populations are required.

Newly Diagnosed Right Coronary Artery Aneurysm in an Adult with Recent Coronavirus Disease 2019 Infection.

It is well known that coronavirus disease 2019 (COVID-19) can affect the vascular endothelium; however, coronary artery aneurysm complicated by COVID-19 in adults has not yet been reported. Herein, we report a case of a newly developed right coronary artery aneurysm in an adult with recent COVID-19 infection. A 66-year-old man was referred for surgical intervention of the right coronary artery aneurysm. His previous coronary angiograms performed 17 months prior revealed no evidence of coronary aneurysm. However, he was confirmed as having COVID-19 four months prior and thereafter newly diagnosed with right coronary artery aneurysm. The further evaluation of the impact of COVID-19 on the occurrence of coronary artery aneurysm may be necessary, considering the alleged correlation between COVID-19 and vascular complications.

Impact of Individual Income Level on Late Mortality After Coronary Artery Bypass Grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) is an important and viable option for patients with symptomatic or life-threatening ischemic heart disease. Few papers have explored whether socioeconomic status is a significantly important determinant in late outcomes of CABG, and individual-level socioeconomic data were particularly scarce. This study was conducted to explore the impact of individual income level on clinical outcomes after CABG. METHODS: This nationwide longitudinal population-based study was conducted in South Korea using the National Health Insurance Service database. Overall, 29 810 adult patients who underwent first-time isolated CABG from 2005 to 2015 were included. The individual income level was stratified into 4 quartiles (Q1-Q4). The primary outcome was overall mortality. RESULTS: After adjustment for preoperative comorbidities, no significant difference in the in-hospital mortality rate was observed between the lowest (income Q1 group) and highest (income Q4 group) quartiles. The risk of overall mortality increased significantly with a reduction in income level, and having an income in the lowest quartile was a significant predictor of worse late mortality compared with the highest quartile (hazard ratio, 1.23; 95% CI, 1.17-1.30). Moreover, the overall incidence of stroke and myocardial infarction was significantly higher in the income Q1 group than in the income Q4 group. The median follow-up duration was 7.0 years (interquartile range, 4.1-10.2 years). CONCLUSIONS: Patients with a lower individual income level had an increased risk of the poorer long-term outcomes after CABG compared with the highest individual income level quartile.

Stent Thrombosis After Short-term Discontinuation of Ticagrelor for Coronary Artery Bypass Grafting.

The optimum antithrombotic strategy before open heart surgery in patients with recently implanted coronary stents has not been clearly established because of lack of clinical evidence. This report describes a case of stent thrombosis in a patient who discontinued a P2Y12 inhibitor (ticagrelor) for 3 days before coronary artery bypass grafting. The period of withdrawal of antiplatelet drugs before coronary artery bypass grafting should be minimized in patients with recently implanted drug-eluting coronary stents to prevent stent thrombosis.

Fate of contralateral asymptomatic bullae in patients with primary spontaneous pneumothorax.

OBJECTIVES: This retrospective cohort study aimed to analyse the impact of asymptomatic blebs/bullae on the occurrence of primary spontaneous pneumothorax (PSP) by monitoring the natural course of contralateral blebs/bullae in patients with ipsilateral pneumothorax. METHODS: From January 2003 to December 2017, 1055 patients [age 19.6 ± 3.98 years (mean ± standard deviation), 953 men] experiencing the first episode of unilateral PSP were enrolled in this study, excluding patients aged 30 years or more. The presence, number and maximal size of the blebs/bullae were investigated in contralateral asymptomatic lungs based on high-resolution computed tomography. RESULTS: Multiple and single blebs/bullae were noted in contralateral lungs in 425 (40.3%) and 88 (8.3%) patients, respectively. The median follow-up period was 44.0 (interquartile range 71.5) months. The 1-, 3- and 5-year cumulative occurrence rates of PSP in contralateral lungs were 7.9%, 13.7% and 16.7%, respectively. On multivariable analysis, younger age [hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.12-1.27; P < 0.001) and multiple bullae (HR 4.42, 95% CI 3.06-6.38; P < 0.001) were independent risk factors for spontaneous pneumothorax in the contralateral lung. The 5-year cumulative occurrence rates of PSP were significantly higher in patients with multiple blebs/bullae than in those with no or a single bleb/bulla (28.2% vs 8.5%, respectively; P < 0.001). CONCLUSIONS: Asymptomatic blebs/bullae often lead to PSP. If the patient is eligible for surgery for pneumothorax, preemptive surgery for contralateral bullae could be considered, especially in patients with multiple blebs/bullae.

Surgical ligation of patent ductus arteriosus in preterm neonates weighing less than 1500g: a 9-year single center experience.

BACKGROUND: The aim of this study was to determine the feasibility and outcomes of early surgical ligation in preterm neonates with hemodynamically significant patent ductus arteriosus (HSPDA) and to investigate predictors for surgical treatment after unsuccessful medical management. METHODS: Medical records from the neonatal intensive care unit of Hanyang University Seoul Hospital from January 2010 to December 2018 were retrospectively reviewed. 233 preterm neonates weighing less than 1500g with HSPDA were enrolled in our study. Of these preterm neonates, 134 underwent surgical ligation and were subdivided into the early ligation group (n = 49; within 10 days of age) and the late ligation group (n = 85; after 10 days of age). RESULTS: The mean gestational age and birth weight were significantly lower in the patent ductus arteriosus (PDA) ligation group than in the Non-ligation group (p <  0.001). PDA ductal diameter > 2.0 mm (p <  0.001), low Apgar score at 5 min (p = 0.033), and chorioamnionitis (p = 0.037) were the predictors for receiving surgical treatment for PDA. Early ligation was significantly associated with a low incidence of culture-proven sepsis (p = 0.004), mechanical ventilator time > 4 weeks (p = 0.007), necrotizing enterocolitis stage (NEC) ≥ III (p = 0.022), and intraventricular hemorrhage (IVH) grade ≥ III (p = 0.035). CONCLUSIONS: Early surgical ligation minimizes the adverse effects of HSPDA in predicted preterm neonates who subsequently require surgical treatment for PDA. This result suggests that in preterm neonates weighing less than 1500g with HSPDA that is unresponsive to medical treatment, delayed ductal closure should be avoided to reduce severe NEC, severe IVH, culture-proven sepsis, and facilitate earlier endotracheal extubation.

Extracorporeal life support for adults with refractory septic shock.

OBJECTIVE: Although the use of extracorporeal membrane oxygenation (ECMO) in shock patients is increasing worldwide, studies concerning this treatment for adult septic shock are limited. This study aimed to analyze the outcome of venoarterial ECMO in adult patients with septic shock refractory to conventional treatment. METHODS: A total of 71 consecutive patients who presented with septic shock and underwent venoarterial ECMO were reviewed. Clinical parameters were compared between survivors and nonsurvivors. Weaning and survival outcomes of these patients were compared with the control group of 253 patients who received venoarterial ECMO for cardiogenic shock. RESULTS: The mean age was 56.0 ± 12.3 years. Of the 71 septic shock patients, 11 (15.5%) were successfully weaned from ECMO after a median of 7.9 [interquartile range (IQR), 6.3-10.2] days, 5 of whom (7.0%) survived to discharge. Pre- and 6 hours post-procedural lactate levels were significantly higher in the nonsurvivors (11.6 [IQR, 7.5-15.0] vs 5.8 [IQR, 4.3-5.9], P = .036; 15.0 [IQR, 11.1-15.0] vs 5.2 [IQR, 4.7-5.4], P = .002). Rates of successful weaning from venoarterial ECMO (15.5% vs 45.5%), and of survival up to hospital discharge (7.0% vs 28.9%) were significantly lower in septic shock than in cardiogenic shock patients (n = 253; P < .001). CONCLUSIONS: Outcomes of ECMO in refractory septic shock patients were poor with a very low probability of survival. This finding raises questions concerning the utility of applying ECMO for medically refractory septic shock. Elevated arterial lactate levels pre- and post-ECMO were associated with risk of in-hospital death. Further large-scale studies are needed to validate the results of this study.

Remnant aortic remodelling in younger patients after acute type I aortic dissection surgery.

OBJECTIVES: To study the influence of age on remnant aortic remodelling after acute DeBakey type I aortic dissection (AD) surgery. METHODS: Between January 1999 and December 2013, 118 acute type I AD patients (26 aged <50 years, Group A; 92 aged ≥ 50 years, Group B) with either ascending or ascending hemiarch replacement in whom preoperative and >1-month postoperative chest computed tomography (CT) were available were included. RESULTS: At median CT follow-up of 35.1 (interquartile range, 14.1-65.2) months, the aortic dimensions in Group A increased significantly from the baseline values at the root, arch and descending thoracic aorta levels at 40.8 ± 5.3 mm to 43.1 ± 6.5 mm ( P = 0.010), 36.8 ± 7.1 mm to 40.7 ± 8.8 mm ( P = 0.043) and 36.7 ± 6.8 mm to 42.8 ± 11.4 mm ( P = 0.009), respectively. In Group B, only the descending thoracic aorta had increased significantly from the baseline at 37.8 ± 4.8 mm to 40.7 ± 9.4 mm ( P = 0.002). Linear regression analysis showed a significant correlation between younger age and aortic size increase, especially at the aortic sinus level. No significant between-group differences in mortality and reoperation rates were seen during the follow-up of 45.0 ± 33.6 months vs 44.1 ± 31.7 months, respectively. CONCLUSIONS: A significantly greater tendency for the remnant aorta to undergo more rapid and generalized adverse remodelling was seen in younger patients after acute type I AD surgery.

Extracorporeal life support for cardiogenic shock: influence of concomitant intra-aortic balloon counterpulsation.

OBJECTIVES: Intra-aortic balloon counterpulsation (IABP) during extracorporeal life support (ECLS) for cardiogenic shock may improve pulsatility and coronary perfusion, thereby promoting recovery of cardiac function. However, the risks and benefits of IABP during ECLS in real clinical settings have not been evaluated. This study aims to evaluate the effect of IABP on the early outcome of ECLS for cardiogenic shock. METHODS: We evaluated 253 adult patients (aged 58.8 ± 15.3 [mean ± standard deviation] years, 154 males) undergoing ECLS for cardiogenic shock from January 2005 to August 2012. Of them, 60 patients underwent concomitant IABP (IABP group) and 193 underwent ECLS only (control group). In-hospital outcomes were compared using the inverse probability of treatment weighting based on propensity scores. RESULTS: The indications for ECLS were low cardiac output after cardiac surgery in 118 patients (46.6%), heart failure in 71 (28.1%), acute myocardial infarction in 49 (19.4%) and others in 15 (5.9%). Successful ECLS weaning rate was significantly higher in the IABP group than in the control group (61.7 vs 42.0%, P = 0.008); however, there was no significant difference in in-hospital mortality between the two groups (68.6 vs 72.0%, P = 0.58). After adjustment for propensity of treatment assignment conditional on baseline characteristics, the IABP group showed a decreased risk of weaning failure (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.28-0.92, P = 0.024) but with a similar risk of in-hospital mortality (OR 0.85; 95% CI 0.46-1.60; P = 0.62) compared with the control group. CONCLUSIONS: The use of IABP during ECLS increased a successful ECLS weaning rate, but was not translated into improved survival. Studies on larger populations may verify the survival effect of IABP during ECLS.

Surgical Ligation on Significant Patent Ductus Arteriosus in Very Low Birth Weight Infants: Comparison between Early and Late Ligations.

BACKGROUND: We aimed to evaluate the efficacy and safety of early surgical ligation (within 15 days of age) over late surgical ligation (after 15 days of age) by a comparative analysis of very low birth weight (VLBW) infants undergoing surgical correction for symptomatic patent ductus arteriosus (PDA) over the course of 6 years in our hospital. METHODS: We retrospectively reviewed all the medical records in the neonatal intensive care unit at Hanyang University Seoul Hospital, from March 2007 to May 2013, to identify VLBW infants (< 1,500 g) who underwent surgical PDA ligation. RESULTS: The gestational age (GA) in the late ligation (LL) group was significantly younger than in the early ligation (EL) group (p=0.010). The other baseline characteristics and preoperative conditions did not differ significantly between the two groups. The intubation period before surgery (p < 0.001) and the age at surgery (p < 0.001) were significantly different. The postoperative clinical outcomes of the study patients, including major morbidity and mortality, are summarized. There were no significant differences in bronchopulmonary dysplasia, sepsis, or mortality between the EL and the LL groups. However, the LL group was significantly associated with an increased risk of necrotizing enterocolitis (p=0.037) and with a prolonged duration of the total parenteral nutrition (p=0.046) after adjusting for GA. CONCLUSION: Early surgical ligation for the treatment of PDA that failed to close after medical treatment or in cases contraindicated for medical treatment might be desirable to reduce the incidence of necrotizing enterocolitis and to alleviate feeding intolerance in preterm infants.

Aortic root conservative repair of acute type A aortic dissection involving the aortic root: fate of the aortic root and aortic valve function.

OBJECTIVES: Despite many studies about aortic valve function and aortic root geometry after conservative aortic root repair of acute type A aortic dissection, the results are not always consistent or conclusive. This study aims to evaluate aortic root diameter and aortic valve function after surgery for acute type A aortic dissection involving the aortic root. METHODS: A retrospective review was performed of 196 consecutive patients (age, 56.9 ± 11.4 years; 96 men) who underwent conservative aortic root repair including sinotubular junction resuspension for the management of acute type A aortic dissection involving the aortic root. RESULTS: The 30-day mortality rate was 5.1% (n = 10). During a median follow-up period of 45.3 ± 36.4 months, there were 28 deaths and 11 cases of aortic reoperation (proximal reoperation in 1 and distal reoperation in 10). Of the 6-month survivors (n = 177, 90.3%), echocardiography and computed tomography were performed in the late period (>6 months) on 115 (65.0%) and 138 (78.0%), respectively. Significant aortic regurgitation (greater than grade 2+) or root dilatation (>45 mm) was observed in 5 and 19 patients, respectively. Freedom from aortic regurgitation (greater than grade 2+) or root dilatation (>45 mm) at 5 years was 84.6% ± 3.9%. On the Cox regression analysis, the maximal aortic root diameter at initial presentation was the only significant predictor of aortic regurgitation and aortic root dilatation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19; P = .014). CONCLUSIONS: Conservative aortic root repair of acute type A aortic dissection demonstrates acceptable long-term clinical outcomes. However, more aggressive approaches should be considered for patients who have aortic root dilatation because of the risk of developing a root aneurysm after surgery.

Mild-to-moderate functional tricuspid regurgitation in patients undergoing mitral valve surgery.

OBJECTIVE: The decision to repair mild-to-moderate functional tricuspid regurgitation (TR) during mitral valve surgery remains controversial. We evaluated the effects of tricuspid valve (TV) repair for functional mild-to-moderate TR during mitral valve surgery. METHODS: We enrolled 959 patients with mild-to-moderate functional TR who underwent mitral valve surgery with (repair group n = 431) or without (control group n = 528) concomitant TV repair from January 1994 to September 2010. RESULTS: There were no significant differences in early mortality or major morbidity rates. Median follow-up was 64.8 months (range, 0.03-203.6 months). After adjustment for baseline characteristics using a propensity score adjustment model, the repair group had similar risks for TV reoperation (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.10-2.07; P = .31); congestive heart failure (HR, 1.12; 95% CI, 0.37-3.36; P = .84); death (HR, 1.41; 95% CI, 0.82-2.42; P = .22); and the composite of death, TV reoperation, and congestive heart failure (HR, 1.24; 95% CI, 0.76-2.03; P = .39) compared with the control group. On multivariate Cox-regression analysis, old age, atrial fibrillation without a Maze procedure, diabetes mellitus, chronic renal failure, poor left ventricular ejection fraction, and redo surgery emerged as significant independent risk factors for the composite outcome of death, TV reoperation, and congestive heart failure. CONCLUSIONS: Early or late clinical benefits of concomitant TV repair for mild-to-moderate TR during mitral valve surgery were uncertain through a long-term follow-up of 959 patients. Several preoperative factors and the performance of Maze procedure for AF seem to be more important than TV repair in overall clinical outcomes.