Impact of maximum phonation time on postoperative dysphagia and prognosis after cardiac surgery.

Objective: The incidence of postoperative complications, including dysphagia, increases as the population undergoing cardiovascular surgery ages. This study aimed to explore the potential of maximum phonation time (MPT) as a simple tool for predicting postextubation dysphagia (PED) and major adverse cardiac and cerebrovascular events (MACCEs). Methods: This retrospective study included 442 patients who underwent elective cardiac surgery at a university hospital. MPT was measured before surgery, and patients were stratified into 2 groups based on normal and abnormal MPTs. Postoperative complications, including PED and MACCEs, were also investigated. Swallowing status was assessed using the Food Intake Level Scale. Results: MPT predicted PED with prevalence of 11.0% and 18.0% in the normal and abnormal MPT groups, respectively (P = .01). During the follow-up period, MACCEs developed in 17.0% of patients. Frailty, European System for Cardiac Operative Risk Evaluation II score, PED, and MPT were markedly associated with MACCEs (adjusted hazard ratios: 2.25, 1.08, 1.96, and 0.96, respectively). Mediation analysis revealed that MPT positively influenced PED and MACCEs, whereas PED positively influenced MACCEs. The trend in restricted cubic spline analysis indicated that the hazard ratio for MACCEs increased sharply when MPT was <10 seconds. Conclusions: These findings underscore the potential of MPT as a valuable tool in the preoperative assessment and management of patients undergoing cardiac surgery. By incorporating MPT into routine preoperative evaluations, clinicians can identify patients at a higher risk of PED and MACCEs, allowing for targeted interventions and closer postoperative monitoring. This may improve patient outcomes and reduce the health care costs associated with these complications.

Quantitative evaluation of middle ear radiopacity in French bulldogs using X-ray imaging.

Background: Radiographic examination of the middle ear in French bulldogs can be challenging due to their small ear cavity and thick walls. Quantifying opacity on radiographic images is required to determine normal or abnormal results. Aim: To quantify the radiographic opacity of the middle ear in French bulldogs and create a threshold for objective diagnosis. Methods: A study was conducted on 32 French Bulldogs using radiographic images. Significant difference tests were performed on the ears of patients with unilateral and bilateral middle ear filling on computed tomography. A threshold was established for detecting left-right asymmetry in the same individuals. In addition, comparisons were made between the filling and nonfilling middle ear groups to establish a threshold of pixel values that could determine single middle ear filling and nonfilling for different patient images. Results: Significant differences were observed in the left-right difference in max, left-right difference in max-ave, and left-right ratio of max-ave between unilateral and bilateral filling groups. The max-ave left-right ratio had the highest area under the curve value with a cutoff of 1.077% and 92.3% sensitivity. The item that showed a significant difference between middle ear groups with and without filling was corrected for nasopharyngeal pixel values with a cutoff of 1.028% and 85% sensitivity. Conclusion: Pixel value ratios in the middle ear region can detect asymmetries in ear densities. The max value in the region compared to the same image's nasopharyngeal region can determine the filling. Combining individual ear evaluations and symmetry improves accuracy.

Anterolateral thoracotomy with partial sternotomy: a feasible approach for treating the complex pathology of the aortic arch.

OBJECTIVES: Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS). METHODS: From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2. RESULTS: Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified. CONCLUSIONS: The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results.

Open Conversion with Explantation of Stent Grafts After Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.

BACKGROUND: Although endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is widely used worldwide, the fact that it is associated with increased rates of reintervention has been considered a problem. This study aimed to analyze the outcomes of primary open AAA repair and open conversion with explantation of stent grafts after EVAR. METHODS: In this retrospective study, we enrolled 1,120 patients (open repair, n = 664; EVAR, n = 456) who underwent AAA repair at Kobe University from 1999 to 2019. Of the 664 patients who underwent open repair, 121 (patients who underwent primary open repair (POR) as a concomitant procedure and patients with ruptured AAA) were excluded from the study. The outcomes of POR were compared with those of open conversion with explantation of stent grafts. RESULTS: Of the 543 patients who underwent open repair, 513 underwent POR and 30 underwent open conversion with explantation of stent grafts. The operation time for POR was significantly less than that for open conversion with explantation. During surgery, patients who underwent open conversion with explantation required significantly more transfusions of red cell concentrate, fresh frozen plasma, and platelet concentrate than those who underwent POR. Overall, 30 patients who underwent open conversion with explantation required a total of 48 reinterventions before surgery. Hospital mortality rates were 0.7% and 0% in the POR and open conversion with explantation groups, respectively (P = 0.62). Although overall survival at 5 years in the POR group was significantly better than that in the open conversion with explantation group (89.3 ± 1.7% vs. 79.5 ± 9.6%; P = 0.01), there were no significant differences between the 2 groups regarding the freedom from aortic event (hospital death, reintervention, and aortic death). According to the multivariate analysis, open conversion with explantation was not an independent risk factor for late death. There were 20 patients who were hesitant to undergo OCE, although we recommended OCE. In a subgroup analysis, the overall mean cost borne by patients who underwent EVAR was approximately 2.3 times higher compared with that borne by patients who underwent POR. CONCLUSIONS: Although demanding, both early and long-term outcomes of OCE have been favorable in our present study. OCE is highly recommended in patients with persistent sac enlargement after EVAR.

Bypass Grafting to Circumflex: Left Internal Thoracic Artery versus Saphenous Vein.

BACKGROUND: This study aimed to compare the short- and long-term outcomes of saphenous vein grafts (SVGs) and in situ left internal thoracic artery (LITA) grafts to the left circumflex artery (LCX) territory. METHODS: This study included 678 patients who underwent LITA-left anterior descending (LAD) + SVG-LCX grafts and 286 patients who underwent right internal thoracic artery (RITA)-LAD + in situ LITA-LCX grafts from January 2002 to December 2020. Short-term and long-term clinical outcomes were compared using inverse probability of treatment weighting adjustment to reduce selection bias. RESULTS: In-hospital mortality was significantly higher for the SVG-LCX group (p = 0.008), whereas deep sternal wound infection was significantly higher in the LITA-LCX group (p = 0.013).Survival rates at 5 and 10 years were 83.12 and 71.45% in the SVG-LCX group, whereas 75.24 and 65.54% in the LITA-LCX group (log-rank p = 0.114). Rates of freedom from cardiac events at 5 and 10 years were 92.82 and 85.24% in the SVG-LCX group, whereas 94.89 and 89.46% in the LITA-LCX group (log-rank p = 0.179).Univariate and multivariate logistic regression analysis showed that proximal severe stenosis was significantly protective against graft dysfunction before discharge (odds ratio, 0.43; 95% confidence interval, 0.23-0.81). CONCLUSION: Deep sternal wound infection was significantly higher for LITA to LCX bypass whereas in-hospital mortality was higher for SVG to LCX. In situ LITA to LCX bypass grafting exhibited similar long-term outcomes with SVG to LCX bypass grafting in adjusted patient cohorts. Proximal severe stenosis of LCX was protective against graft dysfunction.

Postoperative dysphagia as a predictor of functional decline and prognosis after undergoing cardiovascular surgery.

AIMS: Post-extubation dysphagia (PED), an often overlooked problem, is a common and serious complication associated with mortality and major morbidity after cardiovascular surgery. Dysphagia is considered an age-related disease, and evaluating its long-term effects is a pressing issue with rapidly progressing ageing worldwide. Therefore, we examined the effect of PED on functional status and long-term cardiovascular events in patients undergoing cardiovascular surgery. METHODS AND RESULTS: This single-centre, retrospective cohort study included 712 patients who underwent elective cardiovascular surgery and met the inclusion criteria. Patients were divided into PED and non-PED groups based on their post-operative swallowing status. The swallowing status was assessed using the Food Intake Level Scale. Functional status was evaluated as hospital-associated disability (HAD), defined as a decrease in activities of daily living after hospital discharge compared with preoperative values. The patients were subsequently followed up to detect major adverse cardiac and cerebrovascular events (MACCEs). Post-extubation dysphagia was present in 23% of the 712 patients and was independently associated with HAD (adjusted odds ratio, 2.70). Over a 3.5-year median follow-up period, MACCE occurred in 14.1% of patients. Multivariate Cox proportional hazard analysis revealed HAD to be independently associated with an increased risk of MACCE (adjusted hazard ratio, 1.85), although PED was not significantly associated with MACCE. CONCLUSION: Post-extubation dysphagia was an independent HAD predictor, with the odds of HAD occurrence being increased by 2.7-fold due to PED. Hospital-associated disability accompanied by PED is a powerful predictor of poor prognosis. Perioperative evaluation and management of the swallowing status, and appropriate therapeutic interventions, are warranted.

The combination approach with Rhokinase inhibition and mechanical circulatory support in myocardial ischemia-reperfusion injury: Rho-kinase inhibition and ventricular unloading.

BACKGROUND: It remains unclear whether the Rho-kinase (ROCK) inhibition in combination with mechanical circulatory support (MCS) had a synergic protective effect on myocardial ischemia (MI)/reperfusion injury in therapeutic strategies for acute myocardial infarction (AMI). We report the results of an approach using a rat model consisting of a miniaturized cardiopulmonary bypass (CPB) and AMI. METHODS: A total of 25 male Wistar rats were randomized into 5 groups: (1) Sham: a suture was passed under the left anterior descending artery (LAD) creating no MI. A vehicle solution (0.9% saline) was injected intraperitoneally. (2) Myocardial ischemia (MI) + vehicle (MI + V): LAD was ligated for 30 min and reperfused for 120 min, followed by administration of vehicle solution. (3) MI + fasudil (MI + F): the work sequence of group 2, but the selective ROCK inhibitor fasudil (10 mg/kg) was administered instead. (4) MI + V + CPB: CPB was initiated 15 min after the ligation of the LAD to the end of the reperfusion, in addition to the work sequence in group 2. (5) In the MI + F + CPB group, the work sequence of group 4, but with fasudil administration (10 mg/kg). RESULTS: Measurements of cardiac function through conductance catheter indicated that the drop of + dP/dt after reperfusion was moderately limited in MI + F + CPB (vs. MI + V, dP/dt p = 0.22). The preload recruitable stroke work was moderately improved in the MI + F + CPB (p = 0.23) compared with the corresponding control animals (MI + V). Phosphorylated protein kinase B expression in the MI + V + CPB and MI + F + CPB was higher than that in MI + V (p = 0.33). CONCLUSION: Therefore, fasudil administration with MCS resulted in a moderately better left ventricular performance.

Very-long-term outcomes of mechanical valves in mitral position focusing on valve-related complications.

OBJECTIVES: This study aimed to examine very-long-term outcomes of a mechanical valve at the mitral position. METHODS: This study included all patients who underwent mitral valve replacement (MVR) using a mechanical valve including urgent operation at the Department of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, from January 1987 to December 2015. RESULTS: Five hundred and eighty-three patients (277 men [47.51%]; age, 61 [54-67] years) were included in this study. The implanted valve models were as follows: SJM, 221 (37.91%); ATS, 35 (6.00%); On-X, 68 (11.66%); and Carbomedics 194, (33.28%).The median clinical follow-up duration was 13.3 (7.4-19.6) years. The survival rates at 10, 15, 20 and 25 years were 81.42%, 69.27%, 56.34% and 45.03%, respectively. Thromboembolism was observed in 38 patients, and the linearized ratio for each event was 0.626%/patient-year [95% confidence interval (CI), 0.443-0.859%]. Intracranial haemorrhage and gastrointestinal bleeding were observed in 26 and 9 patients, and the linearized ratio for each event was 0.425%/patient-year (95% CI, 0.277-0.006%) and 0.145%/patient-year (95% CI, 0.067-0.276%), respectively. Major paravalvular leak was observed in 32 patients, and the linearized ratio was 0.532%/patient-year (95% CI, 0.364%-0.751%). The cumulative incidence rate of major paravalvular leak at 10, 15, 20 and 25 years was 3.7%, 5.6%, 6.4% and 10.4%, respectively. Multivariable Cox regression analysis revealed that repeated MVR and male gender were associated with major paravalvular leak. CONCLUSIONS: Male gender and repeated MVR were risk factors for paravalvular leak after mechanical MVR. Paravalvular leak could have occurred regardless of postoperative period even at 25 years after implantation. Lifelong clinical follow-up is considered necessary.

Recurrent Pulmonary Embolism Caused by Superficial Femoral Vein Aneurysm.

Venous aneurysms (VA), particularly superficial femoral VAs (SFVAs), are rare vascular lesions. A 65-year-old woman with a history of pulmonary embolism (PE), treated with tissue plasminogen activator and oral anticoagulation, was admitted to hospital for dyspnea. Enhanced computed tomography showed recurrent PE and right SFVA with a mural thrombus. The SFVA was not identified during the first PE. The PE was not massive and was treated with direct oral anticoagulants. The thrombus in the SFVA caused the PE, and surgical repair was performed to prevent further embolic events. Under general anesthesia, the SFVA was excised, and direct anastomosis was performed. PE recurrence, venous aneurysmal changes, and thrombosis were not noted at the 1-year follow-up.

AdipoRon Attenuates Inflammation and Impairment of Cardiac Function Associated With Cardiopulmonary Bypass-Induced Systemic Inflammatory Response Syndrome.

Background Cardiac surgery using cardiopulmonary bypass (CPB) frequently provokes a systemic inflammatory response syndrome, which is triggered by TLR4 (Toll-like receptor 4) and TNF-α (tumor necrosis factor α) signaling. Here, we investigated whether the adiponectin receptor 1 and 2 agonist AdipoRon modulates CPB-induced inflammation and cardiac dysfunction. Methods and Results Rats underwent CPB with deep hypothermic circulatory arrest and were finally weaned from the heart-lung machine. Compared with vehicle, AdipoRon application attenuated the CPB-induced impairment of mean arterial pressure following deep hypothermic circulatory arrest. During the weaning and postweaning phases, heart rate and mean arterial pressure in all AdipoRon animals (7 of 7) remained stable, while cardiac rhythm was irretrievably lost in 2 of 7 of the vehicle-treated animals. The AdipoRon-mediated improvements of cardiocirculatory parameters were accompanied by increased plasma levels of IL (interleukin) 10 and diminished concentrations of lactate and K+. In myocardial tissue, AdipoRon activated AMP-activated protein kinase (AMPK) while attenuating CPB-induced degradation of nuclear factor κB inhibitor α (IκBα), upregulation of TNF-α, IL-1ß, CCL2 (C-C chemokine ligand 2), nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, and inducible nitric oxide synthase. Correspondingly, in cultured cardiac myocytes, cardiac fibroblasts, and vascular endothelial cells, AdipoRon activated AMPK, upregulated IL-10, and attenuated activation of nuclear factor κB, as well as upregulation of TNF-α, IL-1ß, CCL2, NADPH oxidase, and inducible nitric oxide synthase induced by lipopolysaccharide or TNF-α. In addition, the treatment of cardiac myocytes with the AMPK activator 5-aminoimidazole-4-carboxamide 1-ß-D-ribofuranoside resulted in a similar inhibition of lipopolysaccharide- and TNF-α-induced inflammatory cell phenotypes as for AdipoRon. Conclusions Our observations indicate that AdipoRon attenuates CPB-induced inflammation and impairment of cardiac function through AMPK-mediated inhibition of proinflammatory TLR4 and TNF-α signaling in cardiac cells and upregulation of immunosuppressive IL-10.

Evaluation of cerebral blood flow in the hippocampus, thalamus, and basal ganglia and the volume of the hippocampus in dogs before and during treatment with prednisolone.

OBJECTIVE: To examine whether glucocorticoid (GC) administration alters hippocampal cerebral blood flow (CBF) or volume in dogs. ANIMALS: 6 clinically normal adult Beagles. PROCEDURES: Each dog underwent CT and MRI to measure the CBF in the hippocampus, basal ganglia, thalamus, and cerebral cortex and the volume of the hippocampus in each hemisphere of the brain before (day 0) and during (days 7 and 21) a 21-day treatment with prednisolone (1.0 mg/kg, PO, q 24 h) and famotidine (0.5 mg/kg, PO, q 12 h). Results for hippocampal volume, anesthesia-related variables, and semiquantitative measurements of CBF (hemisphere-specific ratios of the CBF in the hippocampus, basal ganglia, and thalamus relative to the CBF in the ipsilateral cerebral cortex and the left cerebral cortex CBF-to-right cerebral cortex CBF ratio) were compared across assessment time points (days 0, 7, and 21). RESULTS: The ratios of CBF in the right hippocampus and right thalamus to that in the right cerebral cortex on day 21 were significantly lower than those on day 0. No meaningful differences were detected in results for the hippocampal volume in either hemisphere or for the anesthesia-related variables across the 3 time points. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that GC administration reduced CBF in the hippocampus and thalamus in dogs of the present study, similar to that which occurs in humans. Research on GC-related brain alteration in dogs could potentially contribute to advancements in understanding Alzheimer disease in humans and neurodegenerative conditions in dogs.

Distal Stent Graft-Induced New Entry after Total Arch Replacement with Frozen Elephant Trunk for Aortic Dissection.

Objectives: Distal stent graft-induced new entry (dSINE), defined as a new tear caused by a stent graft, has been increasingly observed following total arch replacement using frozen elephant trunk (FET) for aortic dissection. We aimed to investigate the incidence and treatment of dSINE after the use of FET. Methods: This retrospective study evaluated 70 patients who underwent total arch replacement using FET for aortic dissection between August 2014 and March 2020. They were followed up for at least 6 months postoperatively. Between-group comparisons were performed between those who did and did not develop dSINE. The risk factors for the development of dSINE and the treatment of dSINE were analyzed. Results: dSINE occurred postoperatively in nine patients (12.9%) with a median time frame of 17.7±11.7 months. The incidence of dSINE did not differ significantly according to classification, phase of dissection, or oversizing. All patients in the dSINE group developed enlargement of the false lumen. dSINE closure was successfully achieved without complications via thoracic endovascular aortic repair (TEVAR) in all patients. Conclusion: No independent factors predicting the development of dSINE were noted in this study. Additional TEVAR for dSINE provides good results and achieves false lumen thrombosis in the thoracic aorta, with no complications.

Long-term Outcomes After Pulmonary Endarterectomy in 499 Patients Over a 20-Year Period.

BACKGROUND: Pulmonary endarterectomy (PEA) is a curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary hypertension (PH) after PEA is not uncommon, and its impact on long-term outcomes is poorly understood. We investigated the effects of residual PH on current long-term survival and on postoperative status. METHODS: Data of 499 consecutive patients who underwent PEA between December 1995 and December 2014 were analyzed retrospectively. Kaplan-Meier survival analysis was used to estimate the survival rates with the 95% confidence interval. RESULTS: Overall survival at 5, 10, and 15 years postoperatively was 84.8% ± 1.9%, 77.1% ± 2.7%, and 59.2% ± 5.3%, respectively. Survival after discharge at 5, 10, and 15 years was 93.9% ± 1.5%, 85.4% ± 2.6%, and 65.6% ± 5.8%, respectively. Of all, 166 patients had residual PH immediately after PEA and a poorer prognosis regarding freedom from CTEPH-related death. CTEPH-related survival at 10 years in patients with normal pulmonary artery pressure vs residual PH was 89.0% ± 2.7% vs 67.9% ± 4.7%, respectively (P < .001). There was a trend to CTEPH-related survival after discharge being affected by residual PH (P = .092). At follow-up, patients with residual PH had worse exercise tolerance (P < .001) and symptoms (P < .001) compared with those with normal pulmonary artery pressure. The probability of developing PH over time was 41.9% at 15 years. CONCLUSIONS: Survival after hospital discharge is excellent for patients undergoing PEA. Postoperative PH is associated with more symptoms and poorer functional capacity. Patients who have clinically relevant postoperative PH should be monitored closely and may be candidates for additional medical therapy.

An Evaluation of the Learning Curve in Pulmonary Endarterectomy Using Propensity Score Matching.

OBJECTIVE: Pulmonary endarterectomy (PEA) is the only causative, but demanding treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). We analyzed our results with PEA to evaluate the learning curve. METHODS: Consecutive 499 patients who underwent PEA between 1995 and 2014 were divided into two groups according to the temporal order: early cohort (n = 200, December 1995-March 2006), and late cohort (n = 299, March 2006-December 2014). We assessed perioperative outcomes after PEA as compared between the early and the late cohort also in propensity-score-matched cohorts. RESULTS: Age at the surgery was older in the late cohort (p = 0.042). Preoperative mean pulmonary artery pressure (mPAP) was 46.8 ± 11.0 mm Hg in the early cohort and 43.5 ± 112.7 mm Hg in the late cohort (p = 0.0035). The in-hospital mortality in the early and late cohorts was 14.0% (28/200) and 4.7% (14/299), respectively (p = 0.00030). The duration of circulatory arrest (CA) became much shorter in the late cohort (42.0 ± 20.5 min in the early and 24.2 ± 11.6 min in the late cohort, respectively, p < .0001). In matched cohorts, the in-hospital mortality showed no significant difference (8.7% in the early cohort and 5.2% in the late cohort, < 0.0001). The CA duration, however, was still shorter in the late cohort (p <0.0001). CONCLUSIONS: Over time, older patients have been accepted for surgery, more patients were operated for lesser severity of CTEPH. Duration of CA and mortality decreased even beyond the first 200 patients, indicating a long learning curve.

Geometry of cusp and root determines aortic valve function.

The aortic valve is the functional unit of cusp and root. Various geometrical and functional analyses for the aortic valve unit have been executed to understand normal valve configuration and improve aortic valve repair. Different concepts and procedures have then been proposed for reparative approach, and aortic valve repair is still not standardized like mitral valve repair. It has become apparent, however, that interpretation of the geometry of the aortic cusp and root and its appropriate application to operative strategy lead to creating a functioning aortic valve. Herein, the aortic valve geometry and its clinical implications are reviewed to provide information for the selection of appropriate operative strategies.

Aortic root remodeling in bicuspid and tricuspid aortic valves-long-term results.

BACKGROUND: Root remodeling is one form of valve-preserving root replacement to treat patients with aortic regurgitation (AR) and root aneurysm. We have consistently used it for patients with and without connective tissue disease and different aortic valve morphologies. The objective of this retrospective study was to review 23 years of experience with root remodeling. METHODS AND PATIENTS: Between 10/95 and 9/2018, 1004 of 1038 root remodeling procedures were performed in patients with tricuspid (n = 589) or bicuspid (n = 414) anatomy of the aortic valve in our institution. Aortic aneurysm was present in 932 cases, 73 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade I to grade IV (mean 2.5 ± 0.8). RESULTS: All patients underwent root remodeling, concomitant operations were performed in 433, and cusp repair in 883 instances. Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10 years and 89% at 15 years. It was 94% for tricuspid valves at 10 and 15 years, and 88% for bicuspid aortic valves at 10 years and 80% at 15 years (p = 0.003). CONCLUSION: In conclusion, root remodeling is a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve form reproducible restoration of aortic valve function can be achieved.

Bilateral papillary muscle repositioning: successful repair of functional mitral regurgitation in dilative cardiomyopathy.

OBJECTIVES: Functional mitral regurgitation (FMR) in patients with non-ischaemic dilative cardiomyopathy (DCM) is associated with heart failure and poor outcome. Aggressively undersized annuloplasty as an annular solution for a ventricular problem ameliorates heart failure but may be associated with recurrent FMR and does not improve survival. We sought to analyse if moderately undersized annuloplasty with repositioning of both papillary muscles can lead to improved valve stability and outcome in patients with DCM and FMR. METHODS: In 66 patients with DCM-associated FMR (age 66 ± 12 years, ejection fraction 29 ± 6% and mean pulmonary artery pressure 35 ± 11 mmHg) and severe leaflet tethering (tenting height ≥10 mm) bilateral papillary muscle repositioning was added to moderately undersized ring annuloplasty (median size 30 mm). Concomitant surgery included tricuspid valve repair in 86% of patients and atrial ablation in 44%. RESULTS: The early mortality rate was 9%. Overall 5-year freedom from all-cause death, left ventricular assist device implantation or heart transplant was 58% (95% confidence interval 45-71%). Six patients underwent reoperation (redo repair n = 4). Reverse remodelling was observed during follow-up in 66% of patients with decreasing left ventricular end-diastolic diameters (66 ± 5 to 61 ± 12 mm; P < 0.001) and left ventricular end-systolic diameters (56 ± 9 to 51 ± 14 mm; P = 0.001). Subgroup analyses (partial versus complete ring, preoperative left ventricular end-diastolic diameters <65 mm vs left ventricular end-diastolic diameter ≥65 mm) documented similar survival rates. A competing risks regression analysis identified cerebral vascular disease (P = 0.01), use of a partial ring (P = 0.03) and absence of tricuspid valve repair (P = 0.03) as independent predictors of death. CONCLUSIONS: The combination of bilateral papillary muscle repositioning and moderately undersized ring annuloplasty leads to stable mid-term repair results and reverse remodelling in patients with DCM and FMR and severe leaflet tethering.

Controlled autologous recellularization and inhibited degeneration of decellularized vascular implants by side-specific coating with stromal cell-derived factor 1α and fibronectin.

Optimized biocompatibility is crucial for the durability of cardiovascular implants. Previously, a combined coating with fibronectin (FN) and stromal cell-derived factor 1α (SDF1α) has been shown to accelerate the in vivo cellularization of synthetic vascular grafts and to reduce the calcification of biological pulmonary root grafts. In this study, we evaluate the effect of side-specific luminal SDF1α coating and adventitial FN coating on the in vivo cellularization and degeneration of decellularized rat aortic implants. Aortic arch vascular donor grafts were detergent-decellularized. The luminal graft surface was coated with SDF1α, while the adventitial surface was coated with FN. SDF1α-coated and uncoated grafts were infrarenally implanted (n = 20) in rats and followed up for up to eight weeks. Cellular intima population was accelerated by luminal SDF1α coating at two weeks (92.4 ± 2.95% versus 61.1 ± 6.51% in controls, p < 0.001). SDF1α coating inhibited neo-intimal hyperplasia, resulting in a significantly decreased intima-to-media ratio after eight weeks (0.62 ± 0.15 versus 1.35 ± 0.26 in controls, p < 0.05). Furthermore, at eight weeks, media calcification was significantly decreased in the SDF1α group as compared to the control group (area of calcification in proximal arch region 1092 ± 517 µm2 versus 11 814 ± 1883 µm2, p < 0.01). Luminal coating with SDF1α promotes early autologous intima recellularization in vivo and attenuates neo-intima hyperplasia as well as calcification of decellularized vascular grafts.