Minimally invasive cardiac surgeries in 2021: annual report by Japanese society of minimally invasive cardiac surgery.

PURPOSE: Although minimally invasive cardiac surgery (MICS) procedures are widely performed throughout Japan, nationwide data regarding treated cases are limited. Up-to-date results for cardiovascular surgery are vital for quality control in clinical practice. Presented here is the 2021 annual report based on data from the Japan Cardiovascular Surgery Database (JCVSD). METHODS: Records noted in the JCVSD of patients who underwent mitral valve surgery, aortic valve replacement (AVR), coronary artery bypass grafting (CABG), atrial septum defect (ASD) closure, or cardiac tumor resection via right or left minithoracotomy, as well as thoracoscopic- or port-assisted, or robotic-assisted approaches, in 2021 were examined. Perioperative parameters including mortality and morbidity was evaluated. RESULTS: The 30-day and in-hospital mortalities for isolated mitral valve repair (n = 1211) were 0.1% and 0.2%, respectively, while those for all mitral valve repair (n = 2017) were 0.05% and 0.2%, respectively. More than 100 facilities were found to perform fewer than five MICS mitral valve surgery cases per year. As for MICS-AVR, 30-day and in-hospital mortalities for isolated AVR (n = 818) were 0.5% and 0.5%, respectively, while those for all AVR (n = 987) were 0.6% and 1.1%, respectively. Additionally, those for MICS-CABG (n = 400) were 0.8% and 0.5%, respectively. Those for ASD (n = 183) and cardiac tumor (n = 96), were 0.5% and 0.5%, respectively, and 0% and 1.0%, respectively. CONCLUSION: This is the first report of MICS results of procedures performed in Japan based on the 2021 JCVSD data. Additional results obtained with a similar data collection method are expected and details on MICS are being collected starting 2024.

Self-expandable transcatheter valve is a potentially useful option for a failing small surgical aortic bioprosthetic valve.

OBJECTIVE: Trans-catheter aortic valve implantation inside a failing surgical aortic valve bio-prosthesis has become an alternative for patients at high risk for redo surgical aortic valve replacement. However, the correlation between the size of the failing surgical aortic valve and the occurrence of prosthesis-patient mismatch after trans-catheter implantation is still controversial. The aim of this study is to analyze and report the results in Japanese patients. METHODS: Thirty patients who underwent trans-catheter aortic valve implantation inside a failing surgical aortic valve at our hospital were retrospectively reviewed with results from echocardiography and computed tomography. RESULTS: The patients' mean age was 84.5 ± 4.8 years. The mean body surface area was 1.42 ± 0.13 m2. The cohort was divided into two groups according to the size of the failing bio-prosthesis: small (≦19 mm) and large (> 19 mm). There were no significant differences in mean pressure gradient (12.2 ± 4.0 mmHg vs. 11.1 ± 1.2 mmHg; p = 0.54) and effective orifice area index (1.00 ± 0.26 cm2/m2 vs. 0.99 ± 0.25 cm2/m2; p = 0.92) between the groups at 6 months after trans-catheter implantation. The incidence of moderate (38.5% vs. 28.6%; p = 0.59) and severe (0% vs. 7.1%; p = 0.33) prosthesis-patient mismatch was equivalent. There was no significant difference in survival between the two groups (log-rank test p-value = 0.08). CONCLUSIONS: Trans-catheter implantation inside a failing small aortic valve did not increase the frequency of prosthesis-patient mismatch in this Japanese cohort.

Efficacy and Safety of Edoxaban in Anticoagulant Therapy Early After Surgical Bioprosthetic Valve Replacement: Rationale and Design of the ENBALV Trial.

BACKGROUND AND PURPOSE: Anticoagulant therapy with vitamin K antagonists is recommended within 3 to 6 months after bioprosthetic valve replacement to prevent thromboembolic events. However, data regarding whether direct oral anticoagulants can be an alternative to warfarin in such patients are limited. The purpose of this study is to compare the efficacy and safety of edoxaban versus warfarin within 3 months after bioprosthetic valve replacement. METHODS: The ENBALV trial is an investigator-initiated, phase 3, randomized, open-label, multicenter study. It involves patients aged 18 to 85 years undergoing bioprosthetic valve replacement at the aortic and/or mitral position. They are randomized 1:1 to receive either edoxaban or warfarin. Administration of edoxaban or warfarin is to be continued for 12 weeks after surgery. The primary outcome is the occurrence rate of stroke or systemic embolism at 12 weeks after surgery. The net clinical outcome is a composite of stroke, systemic embolism, or major bleeding, which is included in the secondary outcomes. CONCLUSION: The ENBALV trial demonstrates the efficacy and safety of edoxaban compared with warfarin in patients early after bioprosthetic valve replacement, including patients with sinus rhythm, which will bring a significant benefit to patients in clinical practice. TRIAL REGISTRATION: Japan Registry of Clinical Trials (jRCT) 2051210209. 30 Mar 2022 https://jrct.niph.go.jp/latest-detail/jRCT2051210209 .

Predictors of postoperative physical functional decline at hospital discharge in elderly patients with prolonged intensive care unit stay after cardiac surgery.

BACKGROUND: A prolonged stay in the intensive care (ICU) is associated with physical function decline following cardiac surgery. To predict physical function decline after cardiac surgery, it may be important to evaluate physical function in the ICU. OBJECTIVES: This study aimed to determine that physical function examination at ICU discharge was independently associated with physical functional decline at hospital discharge in elderly patients who had undergone cardiac surgery and prolonged the ICU stay. METHODS: We assessed physical function before and after cardiac surgery in elderly patients who had spent ≥72 h in the ICU in this retrospective cohort study using the short physical performance battery (SPPB). At hospital discharge, a decrease of at least 1 point on the SPPB was considered a postoperative physical functional decline. Postoperative physical functional decline at hospital discharge was predicted using multiple logistic regression. RESULTS: We revealed postoperative physical functional deterioration in 28.0% of patients who spent ≥72 h in the ICU following cardiac surgery. The Medical Research Council sum score (MRC-SS) (OR: 0.96, 95% CI: 0.82-0.99) and mechanical ventilation days (OR: 1.27, 95% CI: 1.01-1.64) were independently associated with physical functional decline at hospital discharge. CONCLUSIONS: Physical function at ICU discharge and mechanical ventilation days were predictors of postoperative physical functional decline at hospital discharge in patients. MRC-SS was more accurate in predicting postoperative physical functional decline at hospital discharge when performed at the time of ICU discharge.

1-year outcomes of patients implanted with the Perceval sutureless valve: the Japanese post-marketing surveillance study.

Sutureless offers an alternative to standard valves in surgical aortic valve replacement (SAVR). We sought to confirm the efficacy and safety of the Perceval sutureless valve in Japanese patients. Prospective observational study of 204 patients who underwent SAVR with Perceval at 19 sites in Japan between March and December 2019. The primary outcomes were 30-day mortality and postoperative complications; the secondary outcome was all-cause mortality at 1 year. Efficacy outcomes were changed in New York Heart Association (NYHA) class, pressure gradients, effective orifice area (EOA), EOA indexed to body surface area (EOAi) and severity of aortic regurgitation. Mean age was 77.7 years, 62.7% were female. Procedural success rate was 99.0%. The median cross-clamp and cardiopulmonary bypass times were 68.0 and 108 min. Perceval size S and M were implanted in 95 (46.6%) and in 76 (37.3%) of patients, respectively. The 30-day and late mortality rate were 0.5% and 4.4%, while the new permanent pacemaker implantation rate was 4.4%. Mean pressure gradient was 13.0 mmHg at discharge, reaching 11.0 mmHg at 1 year; while the mean EOA was 1.5 cm2 at discharge remaining stable up to 1 year. No moderate or severe leakages were present at discharge or at 1 year. NYHA class improved by ≥ 1 level in 55.1% of the patients at discharge and in 69.4% of the patients at 1 year. 1-year outcomes of SAVR with the Perceval sutureless valve in Japanese patients were favorable. This valve offers a promising alternative to conventional biological AVR in this Japanese population.

Long-term outcomes of combined pulmonary endarterectomy and additional balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

BACKGROUND: The early and long-term outcomes after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have been established by several high-volume centers, but the impact of postoperative residual pulmonary hypertension affecting postoperative clinical parameters remains unclear. This study aims to investigate the institutional surgical results of PEA and to evaluate the efficacy of additional balloon pulmonary angioplasty (BPA) for residual pulmonary hypertension. PATIENTS AND METHODS: We retrospectively reviewed 222 patients (57.7 ± 12.9 years old, 141 female) who underwent PEA for CTEPH at the National Cerebral and Cardiovascular Center between 2000 and 2020. RESULTS: The preoperative mean pulmonary artery pressure (mPAP) was 45.6 ± 9.7 mmHg and pulmonary vascular resistance (PVR) was 1062 ± 451 dyne*sec/cm-5. Postoperative mPAP (23.4 ± 11 mmHg, 204 patients, P < 0.001) and PVR (419 ± 291 dyne*sec/cm-5, 199 patients, P < 0.001) significantly improved after PEA. Since 2011, 62 patients (28%) underwent BPA after PEA for "catecholamine dependent" residual PH 1 month after PEA in 14, "scheduled" BPA with residual PH 1 year after PEA in 32, and 16 "symptomatic" patients without residual PH. Their mPAP had significantly improved by PEA (48.1 ± 7.7 to 32.0 ± 10.2 mmHg, P < 0.001), and further improved (33.8 ± 11.1 to 26.5 ± 9.1 mmHg, P < 0.001) after BPA. CONCLUSIONS: PEA provided immediate and substantial improvements in pulmonary hemodynamics and favorable long-term survival. In addition, postoperative BPA improved postoperative clinical parameters for eligible patients regardless of the presence of residual PH.

Clinically Optimal Neuropsychological Tests for Postoperative Cognitive Dysfunction in Heart Valve Surgeries.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is widely recognized and reported, but the lack of a uniform definition makes it difficult to evaluate its clinical impact. The aim of this study is to establish the optimal neuropsychological tests and definition of POCD relevant to clinical outcomes in heart valve surgeries.Methods and Results: Between June 2015 and December 2019, 315 patients undergoing elective heart valve surgeries (age ≥65 years) were enrolled. The Mini-Mental Status Examination, Montreal Cognitive Assessment (MoCA), and the Trail Making Test A and B were performed to evaluate cognitive function. Clinical endpoints were defined as readmission and death. The postoperative readmission and death rate were 17% and 3% (54/315 and 8/315; follow-up 266-1,889 days). By multivariable Cox hazard analysis, Short Physical Performance Battery (adjusted hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.49-0.98, P=0.001), MoCA change rate (adjusted HR: 0.64, 95% CI: 0.01-1.22, P=0.024), and intensive care unit stay (adjusted HR: 0.55%, 95% CI: 0.99-1.12, P=0.054) were detected as independent risk factors for combined events. The cutoff value was -12% in the change rate of MoCA. CONCLUSIONS: MoCA was the only neuropsychological test that predicted the clinical impact on complex events and has the potential to define POCD.

A novel patch-sparing technique for reconstruction of the aortomitral curtain.

Our goal was to describe a novel technique for reconstructing the aortomitral curtain using autologous tissue. This technique was performed on a patient who required replacement of both the aortic and mitral valves and the aortic root due to recurrent prosthetic valve infection and aortic root abscess. The aortomitral curtain was reconstructed without using any artificial patches. Instead, surrounding autologous tissues were used, including the residual healthy left atrial and aortic basal tissues. This patch-sparing technique may occasionally be feasible to perform and may serve as a secure anchor for subsequent aortic root replacement.

Flow adjusted transmitral pressure gradient as a modified indicator of functional mitral stenosis after repair for degenerative mitral regurgitation.

BACKGROUND AND AIM: After repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes. METHODS: Three hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV. RESULTS: Common mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients' age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038-0.068] vs. 0.041 mmHg/ml, [0.031-0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = -0.37, p < .001). CONCLUSIONS: Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.

Long-Term Outcomes of the Mosaic Mitral Porcine Bioprosthesis in Japan　- Results From the Japan Mosaic Valve Long-Term Multicenter Study.

BACKGROUND: This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic mitral porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:The medical records of 390 patients who underwent mitral valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014) were reviewed. Patient data were collected using the Research Electronic Data Capture software. Patient survival was determined using the Kaplan-Meier method. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined using actuarial methods. The median (interquartile range [IQR]) age of the cohort was 73 (69-77) years. The median (IQR) follow-up period was 4.83 (1.84-8.26) years. The longest follow-up period was 15.8 years. The 30-day mortality rate was 5.4%. The 12-year actuarial survival rate was 54.1±4.5%, and the freedom from valve-related death was 85.3±3.4%. The freedom from reoperation at 12 years was 74.3±5.7%. The freedom from SVD at 12 years was 81.4±6.6% for patients aged ≥65 years and 71.6±11.1% for those aged <65 years. The median (IQR) mean pressure gradient was 4.1 (3.0-6.0) and 5.6 (4.0-6.7) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.7 (1.4-2.0) and 1.4 (1.2-1.6) cm2at 1 and 10 years, respectively. CONCLUSIONS: The Mosaic porcine bioprosthesis offered satisfactory long-term outcomes for up to 12 years.

Surgical Strategy for Chronic Type B Dissecting Aortic Aneurysm to Prevent Aorta-Related Events.

BACKGROUND: This study was aimed to evaluate the outcomes of performing open repair or thoracic endovascular aortic repair for chronic type B dissecting aortic aneurysm. METHODS: From July 2004 to February 2019, 52 patients underwent surgery as open repair (n = 32) or endovascular repair (n = 20) for chronic type B dissecting aortic aneurysm. Replacement of the aorta was limited to the aneurysmal portion with or without reconstructing the visceral arteries or the segmental arteries. Stent grafts were deployed in the true lumen above the celiac artery to cover the primary entry for even DeBakey IIIb dissection. RESULTS: Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. In the endovascular repair group, 3 patients died due to rupture of residual false lumen in the early, and late postoperative follow-up. The 5-year rate of freedom from all-cause death, aorta-related death, and aorta-related event were 84% ± 6%, 94% ± 3% and 84% ± 6%. The endovascular repair was independently associated with all-cause death (hazard ratio [HR], 5.7; confidence interval [CI], 1.02-31.6; P = 0.04) and aorta-related event (HR, 30.9; CI 4.9-195.0; P < 0.001). In the open group, postoperative residual aortic diameter was an independent predictor of aorta-related events, and the threshold was 41 mm. CONCLUSIONS: Open repair remains a better option than simple endovascular repair alone in DeBakey IIIb dissection, but the distal un-resected aortic portion over 41 mm was associated with late aortic events.

Clinical Impact of Flow Adjusted Transmitral Pressure Gradient After Surgical Annuloplasty for Functional Mitral Regurgitation.

Downsizing of mitral annulus due to mitral annuloplasty for ischemic functional mitral regurgitation (FMR) raises a new issue, functional mitral stenosis (FMS), defined as a decline of mitral hemodynamics. However, common mitral hemodynamic parameters are influenced by transmitral flow, therefore, the clinical impacts are still controversial. The aim of this study is to seek mitral hemodynamic indices (including transmitlra pressure gradient [TMPG] adjusted by left ventricular stroke volume [LVSV]) relevant to the mid-term outcomes after annuloplasty for ischemic functional mitral regurgitation (FMR). This study is a retrospective evaluation of mitral valve hemodynamic status by resting echocardiogram at several weeks after surgery. Eighty-one patients underwent mitral annuloplasty for ischemic FMR between September 2012 and June 2019. Postoperative adverse events occurred in 28 patients (34.6%), and the overall 5-year freedom from adverse events rate was 55.9%. Common mitral hemodynamic parameters were not associated with adverse events, but flow adjusted TMPG can be a correlative factor. By multivariable analysis, postoperative systolic pulmonary artery pressure and peak TMPG/LVSV were detected as independent predictors (adjusted hazard ratio 1.07 and 1.08, P < 0.001 and < 0.001). Additionally, risk stratification by peak TMPG (cut-off: 10 mm Hg) and LVSV (cut-off: 35 mL/m2) reflected the mid-term outcomes, perceptively (P = 0.007). Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after annuloplasty for ischemic FMR. However, flow adjusted TMPG was identfied as an independent predictor, and risk stratification by peak TMPG and LVSV reflected the mid-term outcomes, perceptively.

Repair of pacemaker lead-induced right ventricular perforation via a left mini-thoracotomy.

Cardiac perforation is a rare but serious and life-threatening complication of permanent pacemaker implantation, with an incidence of 0.1-6%. Surgery is usually performed through a median sternotomy; however, sternotomy-related morbidity remains a concern. Herein, we report a case of surgical repair performed via a left mini-thoracotomy for a right ventricular perforation caused by implantation of a permanent pacemaker lead in a 56-year-old woman. Through the left fifth intercostal space, the pacemaker lead was observed to have penetrated the left ventricular myocardium, reaching the pericardium. The lead had passed through the right ventricle and the inferior ventricular septum and protruded from the left ventricular myocardium. After pacemaker lead removal, a dark blow-out type hemorrhage occurred; hence, repair was performed using a pair of pledgeted Mattress sutures. In conclusion, left mini-thoracotomy provides an adequate surgical field and has less impact on hemodynamics when operating at the cardiac apex. .

Intraoperative coronary angiography and fractional flow reserve measurement with dobutamine infusion in supra-arterial myotomy for a myocardial bridge: a case report.

BACKGROUND: A myocardial bridge (MB) is a congenital coronary anomaly, wherein the epicardial coronary artery tunnels through the myocardial band. Treatment is indicated when clinical symptoms occur, and ß-blockers are the first choice of treatment. Symptomatic patients refractory to medical therapy are considered for other options, including stent placement, coronary artery bypass grafting, or surgical supra-arterial myotomy. Supra-arterial myotomy is effective; however, the symptoms might persist if myocardial resection is inadequately performed. CASE SUMMARY: We encountered a patient experiencing exertional chest pain. Coronary angiography revealed a MB at the mid-left anterior descending artery with systolic compression. The patient's fractional flow reserves (FFRs) were 0.93 at rest and 0.72 with intravenous administration of 50 µg/kg/min dobutamine. The symptoms were refractory to drugs, and supra-arterial myotomy was performed with intraoperative coronary artery angiography, which revealed the milking effect of the residual myocardium; therefore, additional myocardial resection was performed. Postoperative coronary artery angiography showed no systolic compression, and the postoperative FFRs were 0.88 at rest and 0.92 with intravenous administration of dobutamine 50 µg/kg/min. DISCUSSION: Although surgical supra-arterial myotomy is safe and effective, inadequate myocardial resection might cause symptom recurrence. Intraoperative coronary artery angiography during the surgery can indicate whether additional resection is required. Objective assessment of ischaemia might be useful in cases with a MB, which can cause asymptomatic myocardial ischaemia and sudden cardiac death. FFRs before surgery can help in evaluating the need for surgery and for confirming the therapeutic effect and subsequent treatment.

Primary Minimally Invasive Repair with Atriopericardial Anastomosis Technique for Pulmonary Vein Stenosis after Catheter Ablation.

A pulmonary vein (PV) stenosis is a rare adverse event associated with catheter ablation for atrial fibrillation, which can potentially impair quality of life. Although percutaneous PV angioplasty is performed as the initial treatment of choice, the incidence of restenosis is reported to be considerably high. Herein, we describe a successful case of severe PV stenosis treated by primary surgical repair using the atriopericardial anastomosis technique via right minithoracotomy.

Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes.

BACKGROUND: In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024). CONCLUSIONS: NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.

Incidence, determinants and clinical impact of left ventricular function recovery after surgical treatments for ischaemic cardiomyopathy.

OBJECTIVES: This retrospective study aimed to clarify the incidence, determinants and clinical impact of left ventricular (LV) function non-recovery after coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy. METHODS: A total of 490 patients with ischaemic cardiomyopathy (LV ejection fraction ≤ 40%) undergoing CABG were analysed. Follow-up echocardiography was performed at 1 month, 1 year, and annually thereafter. LV function recovery was defined as ejection fraction (EF) ≥40% at least once during follow-up. LV function non-recovery was defined as EF <40% at any follow-up. The primary and secondary end points were changes in LV function and all-cause mortality, respectively. Clinical follow-up was completed in 461 patients (94.1%; mean follow-up: 64.5 ± 45.5 months). RESULTS: During follow-up, echocardiographic assessments were performed 1863 times (mean, 3.8 ± 2.4), and 193 patients (39.4%) exhibiting LV function non-recovery were identified. Overall survival was significantly higher in the recovery group (53.9%) than in the non-recovery group (31.4%) at 10 years (P < 0.001). Independent predictors of LV function non-recovery were preoperative LV end-systolic diameter [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04-1.10; P < 0.001] and bilateral internal thoracic artery grafting (OR 0.61, 95% CI 0.39-0.95; P = 0.028). In a multivariable Cox proportional hazards model, LV function non-recovery was significantly associated with all-cause mortality (hazard ratio 2.14, 95% CI 1.60-2.86; P < 0.001). CONCLUSIONS: Almost 40% of patients with ischaemic cardiomyopathy undergoing CABG did not achieve LV function recovery and were associated with poor prognosis. To achieve LV function recovery, CABG with bilateral internal thoracic artery may be recommended before excessive LV remodelling occurs. CLINICAL TRIAL REGISTRATION NUMBER: Institutional review board of Osaka University Hospital, number 16105.

Predictors of Functional Decline in Activities of Daily Living at Discharge in Patients After Cardiovascular Surgery.

BACKGROUND: This study aimed to investigate the trajectory of functional recovery of activities of daily living (ADL) from the time of admission up to hospital discharge, and explored which preoperative and postoperative variables were independently associated with functional decline in ADL at discharge of patients after cardiovascular surgery.Methods and Results:In this observational study, we evaluated ADL preoperatively and at discharge using the Functional Independence Measure (FIM) in patients after cardiovascular surgery. Functional decline in ADL was defined as scoring 1-5 on any one of the FIM items at discharge. Multiple logistic regression was performed to predict the functional decline in ADL at discharge. We found that 18.8% of elective cardiovascular surgery patients suffered from decreased ADL at discharge. The Mini-Mental State Examination (odds ratio (OR): 0.573, 95% confidence interval (CI): 0.420-0.783), gait speed (OR: 0.032, 95% CI: 0.003-0.304) and initiation of walking around the bed (OR: 1.277, 95% CI: 1.103-1.480) were independently associated with decreased ADL at discharge. CONCLUSIONS: A functional decline in ADL at discharge can be predicted using preoperative measures of cognitive function, preoperative gait speed and postoperative day of initiation of walking. These results show that preoperative cognitive screening and gait speed assessments can be used to identify patients who might require careful postoperative planning, and for whom early postoperative rehabilitation is needed to prevent serious functional ADL deficits.

Surgical Ablation Concomitant With Nonmitral Valve Surgery for Persistent Atrial Fibrillation.

BACKGROUND: Consensus regarding an optimal atrial fibrillation (AF) ablation lesion set concomitant with aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) has not been established. METHODS: We enrolled 125 consecutive patients (89 men; 70 ± 8 years old) with persistent AF who underwent radiofrequency-based pulmonary vein isolation (PVI) (PVI group, n = 53) or a Cox-Maze procedure (Maze group, n = 72) with AVR and/or CABG. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent Cox-Maze with and those who underwent PVI, we established weighted Cox proportional-hazards regression models with inverse probability of treatment weighting. Mean follow-up was 63 ± 34 months (maximum, 154 months). RESULTS: There was 1 in-hospital death in each group. Patients who underwent Cox-Maze showed a higher freedom from AF at all follow-up examinations. After the operation, there were 32 deaths, 13 thromboembolisms, 8 hemorrhagic events, and 22 heart failure readmissions. The Maze group had higher rates for 5-year survival (88% vs 64%, P = .013) and freedom from composite events (74% vs 42%, P < .001). After adjustment with inverse probability of treatment weighting, the Cox-Maze procedure still showed a lower risk of overall mortality (adjusted hazard ratio, 0.38; 95% confidence interval, 0.21-0.66; P = .001) and composite adverse events (adjusted hazard ratio, 0.52; 95% confidence interval, 0.35-0.76; P = .001). CONCLUSIONS: In patients with persistent AF indicated for nonmitral valve surgery, a concomitant Cox-Maze procedure resulted in superior AF- and event-free survival compared with PVI, without increased risk of early mortality. These findings may assist decision making for surgical management of persistent AF concomitant with AVR and/or CABG.