Extended Posterior Leaflet Augmentation for Ischemic Mitral Regurgitation　- Augmented Posterior Leaflet Snuggling up to Anterior Leaflet.

BACKGROUND: The ideal surgical technique for ischemic mitral regurgitation (MR) is controversial. We introduced an extended posterior mitral leaflet (PML) augmentation technique for functional MR with severe tethering, which detached the PML from the annulus almost completely and augmented it with a large 3×6-cm oval pericardial patch. Methods and Results: A total of 17 mitral repairs using the new technique were performed for ischemic MR with no 30-day mortality and 2 hospital deaths. The NYHA class was III in 47% and IV in 13%. The EuroSCORE II was 9.7±4.9. The ring size was 32±1.4 mm. Concomitant coronary bypass was performed in 67% and left ventricular repair in 28%. The mechanism of leaflet closure was evaluated using transthoracic echocardiography in 15 survivors. MR decreased to none or trivial with a significant increase in coaptation length (Pre: 4.6±0.8 mm vs. Post: 9.8±2.5 mm; P<0.001). The PML flexibly moved forward and tightly contacted as if "snuggling up" to the anterior leaflet. There were no late deaths, heart failure readmissions or MR recurrences during follow-up (850±181 days). All patients remained in NYHA I or II. CONCLUSIONS: Extended PML augmentation for ischemic MR showed excellent early results with deep leaflet coaptation through a "snuggling up" phenomenon, which would help prevent late MR recurrence.

Preemptive angioplasty for contralateral leg stenosis following EXCLUDER Iliac Branch Endoprosthesis implantation.

The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE) device is designed to seal off a common iliac artery (CIA) aneurysm, preserving the internal iliac artery during endovascular aortic repair. We report the case of an 84-year-old man with isolated saccular right CIA aneurysm (35 mm) and a relatively small terminal aorta (24 mm). The IBE device was successfully placed, and intraoperative angiography revealed no leakage or delay. However, postoperative computed tomography revealed marked compression of the contralateral leg by a bridging component. Although his ankle-brachial index was preserved, its acute occlusion was judged highly possible; we decided to perform preemptive angioplasty. The angiography revealed the stenosis only in the left anterior oblique view, and angioplasty was uneventfully performed. The leg was successfully patent at 1-year follow-up. When compression by IBE and bridging component in the terminal aorta is expected, caution should be preserved at intraoperative angiography following the device deployment.

Risk Factors for Atrial Fibrillation Recurrence After Cox Maze IV Performed Without Pre-exclusion.

BACKGROUND: New guidelines from The Society of Thoracic Surgeons recommend adding surgical ablation as a concomitant procedure for class I indications. We performed the maze procedure for all patients who experienced atrial fibrillation (AF) before cardiac surgery, without surgeon pre-exclusion. METHODS: We retrospectively analyzed 83 patients, aged 71 ± 11 years (22% >80 years), who underwent Cox maze IV for persistent AF between 2014 and 2017. The mean AF duration (AFD) was 6.9 ± 8.6 years and European System for Cardiac Operative Risk Evaluation II was 7.2 ± 6.8. RESULTS: The 30-day mortality was 2.4%. During follow-up (mean, 675 days), the 1-, 2-, and 3-year survival rates were 92%, 86%, and 82%, respectively. No strokes were observed despite a mean CHA2DS2-VASC (Congestive heart failure, Hypertension, Age [≥65 = 1 point, ≥75 = 2 points], Diabetes, and Stroke/transient ischemic attack [2 points], vascular disease, Sex [female = 1 point]) score of 4.1 (expected stroke rate, 4%/y). Twelve patients required a new pacemaker; 56 of 73 survivors (77%) remained AF free. Multivariate logistic regression identified preoperative AFD, f wave size, and mean heart rate per Holter as important risk factors for AF recurrence, with AFD as the most important: 98% of patients with AFD less than 5 years remained AF free. Although the AF-free rate with the AFD of 5 or more years was only 55%, their symptoms improved without heart failure readmission. Concomitant atrial plication was performed more frequently in the group with AFD for 5 or more years, with greater atrial volume reduction and appreciable increases in stroke volume. CONCLUSIONS: The Cox maze IV procedure performed without pre-exclusion showed reasonable survival rates. Although AF recurred in patients with longer AFD, they fared well with substantial increases in stroke volume. Concomitant atrial volume reduction may have contributed to these additional benefits.

Rapidly Progressed Distal Arch Aneurysm with Distal Open Stent Graft-Induced New Entry Caused by "Spring-Back" Force.

The J Graft Open Stent Graft (JOSG) is used for the frozen elephant trunk procedure in Japan. We report a 70-year-old male who developed a rapidly progressing distal arch aneurysm caused by a distal stent graft-induced new entry (DSINE) 7 months after the procedure. The JOSG was originally implanted at the curved part of the distal arch. It created its initial DSINE on the greater curve and rapidly "sprang" back in 2 months. Urgent thoracic endovascular aortic repair fixed this serious complication. We should remember such rapid progression of DSINE by JOSG and treat its initial sign earlier.