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 .

Mid-term outcomes of surgical aortic valve replacement using a mosaic porcine bioprosthesis with concomitant mitral valve repair.

This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75 years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.

Side-by-side deployment of gore excluder legs at a narrow terminal aorta for endovascular aneurysm repair.

PURPOSE: A narrow terminal aorta is a risk factor for endograft occlusion after endovascular aneurysm repair. To minimize limb complications, we used Gore Excluder legs positioned side-by-side at the terminal aorta. We investigated the outcomes of our strategy for endovascular aneurysm repair in patients with a narrow terminal aorta. METHODS: We enrolled 61 patients who underwent endovascular aneurysm repair with a narrow terminal aorta (defined as < 18 mm in diameter) from April 2013 to October 2021. The standard procedure involves complete treatment with the Gore Excluder device. When other types of main body endografts were used, they were deployed proximal to the terminal aorta, and we used the Gore Excluder leg device in the bilateral limbs. Postoperatively, the intraluminal diameter of the legs at the terminal aorta was measured to assess the configuration. RESULTS: During the follow-up period (mean: 2.7 ± 2.0 years), there were no aorta-related deaths, endograft occlusions, or leg-related re-interventions. There were no significant differences between the pre- and postoperative ankle-brachial pressure index values in the dominant and non-dominant legs (p = 0.44 and p = 0.17, respectively). Postoperatively, the mean difference rate (defined as [dominant leg diameter-non-dominant leg diameter]/terminal aorta diameter) was 7.5 ± 7.1%. The difference rate was not significantly correlated with the terminal aortic diameter, calcification thickness, or circumferential calcification (r = 0.16, p = 0.22; r = 0.07, p = 0.59; and r = - 0.07, p = 0.61, respectively). CONCLUSIONS: Side-by-side deployment of Gore Excluder legs produces acceptable outcomes for endovascular aneurysm repair with a narrow terminal aorta. The endograft expansion at the terminal aorta is tolerable without influencing calcification distribution.

Serial changes in cardiac sympathetic nervous function after transcatheter aortic valve replacement: A prospective observational study using 123I-meta-iodobenzylguanidine imaging.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) can rapidly improve cardiac sympathetic nervous function (CSNF) within 2 weeks in patients with aortic stenosis (AS). However, whether such short-term improvements will be sustained thereafter remains unclear. METHODS: Patients with severe AS who underwent TAVR between October 2017 and June 2019 were enrolled in this single-center, prospective, observational study. 123I-meta-iodobenzylguanidine imaging was performed at baseline, within 2 weeks after TAVR, and at 6 to 12 months post-TAVR to evaluate the heart-mediastinum ratio (H/M) and washout rate. RESULTS: Of 183 consecutive patients, 75 (19 men; median age: 86 years) were evaluated. The late H/M significantly improved within 2 weeks after TAVR (P = .041) and further improved over 6 to 12 months after TAVR (P = .041). Multivariate analysis revealed that the baseline mean aortic valve pressure gradient (mPG) was an independent predictor of mid-term improvement in the late H/M (> 0.1) (P = .037). Patients with a high baseline mPG (≥ 58 mmHg) exhibited a significantly greater increase in the late H/M than those with a low baseline mPG (< 42 mmHg) (0.24 vs 0.01; P = .029). CONCLUSION: CSNF demonstrated sustained improvement from within 2 weeks after TAVR until 6 to 12 months later. Such improvement was related to baseline hemodynamic AS severity.

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.

A tissue-engineered, decellularized, connective tissue membrane for allogeneic arterial patch implantation.

BACKGROUND: We have previously applied in vivo tissue-engineered vascular grafts constructed in patients' subcutaneous spaces. However, since the formation of these vascular grafts depends on host health, their application is challenging in patients with suppressed regenerative ability. Therefore, the allogeneic implantation of grafts from healthy donors needs to be evaluated. This study aimed to fabricate allogeneic cardiovascular grafts in animals. MATERIALS AND METHODS: Silicone rod molds were implanted into subcutaneous pouches in dogs; the implants, along with surrounding connective tissues, were harvested after four weeks. Tubular connective tissues were decellularized and stored before they were cut open, trimmed to elliptical sheets, and implanted into the common carotid arteries of another dog as vascular patches (n = 6); these were resected and histologically evaluated at 1, 2, and 4 weeks after implantation. RESULTS: No aneurysmal changes were observed by echocardiography. Histologically, we observed neointima formation on the luminal graft surface and graft wall cell infiltration. At 2 and 4 weeks after implantation, α-SMA-positive cells were observed in the neointima and graft wall. At 4 weeks after implantation, the endothelial lining was observed at the grafts' luminal surfaces. CONCLUSION: Our data suggest that decellularized connective tissue membranes can be prepared and stored for later use as allogeneic cardiovascular grafts.

Sufficient cardiac unloading by Impella 5.0 in left ventricular rupture following mitral valve replacement: a case report.

A 72-year-old woman presented with exertional dyspnea. Echocardiography revealed severe mitral valve stenosis; therefore, mitral valve replacement was performed using a bioprosthetic valve. However, left ventricular wall rupture occurred following mitral valve replacement. Under re-cardiac arrest, we found a left ventricular tear under the posterior annulus of the mitral valve. We repaired the left ventricular muscle using a bovine pericardial patch and implanted a bioprosthetic valve again. Postoperatively, we implanted an Impella 5.0 heart pump through the right axillary artery to ensure left ventricular wall unloading. Systemic blood flow depended almost completely on mechanical circulatory assistance until postoperative day 3. After the fourth postoperative day, we started weaning the patient from Impella 5.0. Finally, it was completely discontinued on the sixth postoperative day. After that, the patient's condition was stable, and she was discharged 44 days postoperatively. Impella 5.0 is a potentially beneficial device for left ventricular unloading in patients with left ventricular wall rupture following mitral valve replacement.

[Robot-assisted Cardiac Surgery Council and Current Status and Future Prospect of Robotic Mitral Valve Surgery in Japan].

The Robot-assisted Cardiac Surgery Council (RACSC) was established in 2015, and consists of the members of three closely related surgical societies and associations. The RACSC conducts the review and approval of applicant surgeons and institutions. A registry system has also been established through the Japan Cardiovascular Surgery Database-National Clinical Database( JCVSD-NCD). For the last five years, including the time when robotic mitral valve surgery was first approved as a procedure covered by the Japanese social insurance system in 2018, a total of 1,161 patients were enrolled in the JCVSDNCD, with an increase of nearly 500 cases per year. These cases underwent operations in 25 approved hospitals. The mean patient age was 59±13 years( range:20-90 years), and the male to female patient ratio was 1.8 male dominant. The most common procedure was mitral valve reconstruction, and 79% of all patients underwent annuloplasty. The mean operative time was 238±100 min, the mean cardiopulmonary bypass (CPB) time was 158±69 min, and the mean aortic cross-clamp (AXC) time was 102±49 min. When these results were compared with those of the Cleveland Clinic, which treated more than 1,000 cases as an initial institutional experience, both CPB and AXC times were nearly the same. It is believed that 200 cases are needed to stabilize the CPB and AXC time. Currently in Japan, only 3 or 4 out of the 25 approved hospitals have performed more than 200 cases over the past 5 years. The 30-day hospital mortality and redo operation rate for persisting mitral regurgitation was 0.3% and 0.6%, respectively, almost equivalent to that of the Cleveland Clinic. We believe that the 5-year result for robotic mitral surgery in Japan is acceptable. It is of note, however, that the length of hospital stay was 10.8±7.6 days, much longer than that of patients at the Cleveland Clinic( 5.2±2.8 days), and the homologous blood transfusion rate was 40.3%, twofold higher than that of the Cleveland Clinic( 20.5%). Therefore, the full benefits of less invasive robotic mitral repair surgery have not yet been achieved. Further improvements in results are both essential and anticipated.

Two-Year Results of the 17-mm Avalus Aortic Valve in the PERIGON Japan Trial.

BACKGROUND: The PERIcardial SurGical AOrtic Valve ReplacemeNt (PERIGON) Japan Trial was developed to assess the safety and effectiveness of the 17-mm Avalus bioprosthesis (Medtronic, Minneapolis, MN, USA) in patients undergoing surgical aortic valve replacement.Methods and Results:The primary endpoint in the trial was the percentage of patients achieving the composite of at least 1 class improvement in New York Heart Association (NYHA) functional class at 1 year compared with baseline and effective orifice area index (EOAI) of 0.6 cm2/m2or greater at 1-year after implantation, compared with a performance goal of 60%. The present study reports outcomes through 2 years. Eleven patients were implanted (10 [91%] female, median age 78.3 years). From baseline to 1 year, 10 subjects (91%) showed an improvement in NYHA classification. At 1 year, mean (±SD) EOAI was 0.82±0.17 cm2/m2, with 10 patients (91%) having an EOAI ≥0.6 cm2/m2. As such, 9 of 11 patients (82%) successfully met the primary endpoint. One death occurred between the 1- and 2-year follow-up visits, unrelated to the valve. There were no valve reinterventions, explants, or device deficiencies through 2 years. CONCLUSIONS: The PERIGON Japan Trial met its primary endpoint. Surgical implantation of the 17-mm Avalus aortic bioprosthesis can be performed with an acceptable incidence of device-related adverse events, and the valve performs effectively based on echocardiographic findings.

[Valve Surgery after Coronary Artery Bypass Grafting].

It has been reported that there are some risks of coronary artery graft injury while redo sternotomy was required for valve surgery after coronary artery bypass grafting (CABG). Also it is well known that clinical results after graft injury was poor. For avoiding graft injury, coronary artery graft must be placed away from the sternum at the time of initial CABG. For redo sternotomy, 3-dimensional-computed tomography can be useful. For aortic valve surgery after CABG, treatment of patent in-situ graft have to be discussed. For common practice, dissecting and clamping the patent in-situ graft during cardiac arrest were required. However, there are some reports showing good clinical results with moderate hypothermia, non-dissection and non-clamping graft. Furthermore, less mobidity rate results of transcatheter aortic valve implantation( TAVI) after CABG was reported. For mitral valve surgery after CABG, right mini-thoracotomy was reported as preferred procedure recently. Dissection area could be reduced than re-median sternotomy, although clamping aorta and patent graft were technically difficult. Two procedures were reported such as hypothermia and ventricular fibrillation or normothermia and beating heart. MitraClip procedure can be considered for high risk patients. Newly developed surgical and catheter technique may change the strategy for heart valve disease after CABG.

Early effects of transcatheter aortic valve replacement on cardiac sympathetic nervous function assessed by 123I-metaiodobenzylguanidine scintigraphy in patients with severe aortic valve stenosis.

PURPOSE: The effects of transcatheter aortic valve replacement (TAVR) on cardiac sympathetic nervous (CSN) function have not been fully explored. This study aimed to investigate the early (within 2 weeks) effects of TAVR on CSN function in patients with severe aortic valve stenosis (AS) using 123I-metaiodobenzylguanidine (MIBG) scintigraphy. METHODS: Of 143 consecutive patients who were scheduled to undergo TAVR, 67 (18 men; median age 86 years) were evaluated in this single-centre prospective observational study. MIBG scintigraphy was performed at baseline and 3-14 days after the TAVR procedure to evaluate the heart-mediastinum ratio (H/M) and washout rate (WR). Differences between baseline and post-TAVR MIBG parameters were analysed. MIBG parameter changes were compared with echocardiographic parameters. Furthermore, factors involved in the improvement in MIBG parameters were investigated. RESULTS: All patients successfully underwent TAVR with improved echocardiographic parameters, including aortic valve area (AVA; 0.6 cm2 vs. 1.6 cm2), peak velocity (4.5 m/s vs. 2.0 m/s), mean pressure gradient (50 mmHg vs. 9 mmHg), and left ventricular ejection fraction (56% vs. 62%) (all p < 0.001). On MIBG imaging, delayed H/M significantly increased (2.57 vs. 2.68, p < 0.001), whereas WR decreased (32.2% vs. 26.8%, p < 0.001). In multivariate analysis, higher baseline WR was associated with improvement in WR (> 3%). Female sex, Clinical Frailty Scale score ≤ 5, baseline estimated glomerular filtration rate, and baseline AVA were predictors of improvement in delayed H/M (> 0.1). Baseline AVA and E/E' were independent predictors of improvement in both WR and delayed H/M. CONCLUSIONS: The CSN function was impaired in patients with AS, as assessed using MIBG scintigraphy. WR and delayed H/M improved immediately after TAVR. Improvement in CSN function may be related to echocardiographic AS severity at baseline before TAVR.

Long-Term Outcomes of the Mosaic Aortic 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 aortic porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:We reviewed the records of 1,202 patients who underwent aortic valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014). Patient data were collected using Research Electronic Data Capture. Patient survival was determined by Kaplan-Meier methodology. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined by actuarial methods. The median (interquartile range [IQR]) age of the cohort was 76 (70-80) years. The median (IQR) follow-up period was 3.52 (1.71-5.35) years. The longest follow-up was 15.8 years. The 30-day mortality rate was 2.3%. The 12-year actuarial survival rate was 59.9±7.5%, and the freedom from valve-related death was 81.1±7.9%. The freedom from reoperation was 86.4±2.6% at 12 years. The freedom from SVD at 12 years was 93.5±2.9% for patients aged ≥65 years and 98.2±1.8% for those aged <65 years. The median (IQR) systolic pressure gradient was 17 (12-23) and 19 (12-25) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.2 (1.1-1.5) and 1.1 (1-1.5) cm2at 1 and 10 years, respectively. CONCLUSIONS: The Mosaic porcine bioprosthesis showed satisfactory long-term outcomes over 12 years.

Surgical intervention for ischemic mitral regurgitation: how can we achieve better outcomes?

Ischemic mitral regurgitation (MR) is a common complication of myocardial infarction. Left ventricular (LV) dysfunction and distortion of the subvalvular apparatus are the main contributors to ischemic MR. Coronary artery bypass grafting alone, mitral valve replacement, and mitral valve repair, with or without subvalvular procedures, have been performed for moderate-to-severe ischemic MR. Several randomized studies on the surgical treatment of ischemic MR have been performed; however, the optimal surgical strategy remains controversial because none have demonstrated a clear survival benefit. Since the mechanisms of ischemic MR are complex and multifactorial, comprehensive preoperative assessment of LV function and geometry (both global and regional), mitral valve configuration, viability testing, and exercise echocardiography are needed. A better understanding of this complicated disease and of the advantages and limitations of each procedure may help us devise more effective patient-specific surgical treatment strategies and achieve better outcomes.

[Functional Mitral Stenosis after Mitral Valve Repair for Degenerative Mitral Valve Regurgitation].

Functional mitral stenosis after mitral valve repair for degenerative mitral regurgitation( DMR) is an evolving concept. Mitral annuloplasty devices stabilize the mitral annulus, reduce leaflet stress and increase leaflet coaptation, which leads to improvement of repair durability at the cost of dynamic and physiological annular movement and diastolic annular area. An elevation in rest and peak transmitral gradient has been observed in some patients with annuloplasty devices, and this elevation may associate with worse prognosis as late atrial fibrillation or lower functional capacity after surgery. In this review, we summarize the current reports describing functional mitral stenosis after mitral valve repair for DMR.

Development of xenogeneic decellularized biotubes for off-the-shelf applications.

In earlier studies, we developed in vivo tissue-engineered, autologous, small-caliber vascular grafts, called "biotubes," which withstand systemic blood pressure and exhibit excellent performance as small-caliber vascular prostheses in animal models. However, biotube preparation takes 4 weeks; therefore, biotubes cannot be applied in emergency situations. Moreover, for responses to various types of surgery, grafts should ideally be readily available in advance. The aim of this study was to develop novel, off-the-shelf, small-caliber vascular grafts by decellularizing in vivo tissue-engineered xenogeneic tubular materials. Silicone rod molds (diameter: 2 mm, length: 70 mm) placed in subcutaneous pouches of a beagle dog for 4 weeks were harvested with their surrounding connective tissues. Tubular connective tissues were obtained after pulling out the impregnated molds. Subsequently, they were decellularized by perfusion with sodium dodecyl sulfate and Triton X-100. They were stored as off-the-shelf grafts at -20°C for 1 week. The decellularized grafts derived from the beagle dog were xenogeneically transplanted to the abdominal aortas of rats (n = 3). No signs of abnormal inflammation or immunological problems due to the xenogeneic material were observed. Echocardiography confirmed the patency of the grafts at 1 month after implantation. Histological evaluation revealed that the grafts formed neointima on the luminal surface, and that the graft walls had cell infiltration. Little accumulation of CD68-positive macrophages in the graft wall was observed. Xenogeneic decellularized tubular tissues functioned as small-caliber vascular grafts, as well as autologous biotubes. This technology enables the easy fabrication of grafts from xenogeneic animals in advance and their storage for at least a week, satisfying the conditions for off-the-shelf grafts.

[Adult Congenital Heart Surgery as a Novel Specialty in Thoracic Surgery; Perioperative Patient Management and Surgical Procedures].

Recently, number of adult congenital heart disease(ACHD) patients are rapidly increasing, but statistical evidences in adult congenital heart surgery are not sufficient because of its short history in addition to the complicated pathophysiology of ACHD. Therefore, a "heart team" including surgeons, pediatricians, and cardiologists are required, and blood flow imaging and 4-dimensional (4D) imaging plays an essential role in perioperative patient management. Enhanced 3-dimensional computed tomography( 3D-CT) scan is useful to determine cardiopulmonary bypass strategies in reoperation, and 4D flow magnetic resonance imaging( MRI) is useful in assessment of complicated hemodynamics. Diastolic function of systemic ventricle is very important in right side heart valve surgery or univentricular heart surgery, echocardiography is essential to examine the valve structure, and electrophysiological mapping is useful in concomitant arrhythmia surgery. This article describes the indications, procedures, and perioperative managements of surgery in the right ventricular outflow tract, tricuspid valve, aortic root, Fontan circulation, and systemic right ventricle.

[A Case of Aortic Graft Infection Due to Listeria monocytogenes Detected by Microarray-Based, Multiplexed, Automated Molecular Diagnosis System].

A 80-year-old man was transferred to our hospital for hemoptysis caused by erosion(perforation) of thoracic aortic stent graft infection into the airway. Blood cultures on admission detected Gram-positive rods, and a microarray-based, multiplexed, automated molecular diagnosis instrument (Verigene® system) identified Listeria spp. Although Listeria monocytogenes is rare organism of stent graft infection, we were able to start appropriate antibiotic therapy on the second hospital day due to rapid identification of bacteria. Verigene® system is considered to be useful in severe infectious diseases including stent graft infections, even if the causative organism is rare.

Brachial-Ankle Pulse Waves Reflect the Hemodynamics of Valvular Heart Disease.

BACKGROUND: Brachial-ankle pulse wave (ba-PW) analysis is an established technique for assessing arterial stiffness and cardiovascular risk. The peripheral arterial pulse wave configuration may be useful for valvular heart disease (VHD) detection because it is closely related to the physical signs of VHD; however, few reports have been made assessing the efficacy of ba-PW analysis for VHD screening. METHODS: Consecutive VHD patients scheduled for valve surgery were enrolled in the study. These included 58 patients with aortic stenosis (AS) (mean age 74 ± 1.1 years), 67 with aortic regurgitation (AR) (mean age 59 ± 1.9 years), and 65 with mitral regurgitation (MR) (mean age 62 ± 1.6 years). Ba-PW analysis was conducted using the VaSera VS-1500 screening system before and after surgery. Upstroke time (UT), ejection time (ET), pre-ejection period (PEP), PEP/ET ratio, mean arterial pressure (%MAP), and cardio-ankle vascular index (CAVI) were compared with a control group (n = 65; mean age 69 ± 1.5 years) without VHD. RESULTS: The UT was significantly shorter in the AR group (132.9 ± 4.0 ms) and MR group (134.5 ± 2.5 ms), but significantly longer in the AS group (178.2 ± 2.8 ms) compared to controls (149.6 ± 3.6 ms; all p <0.01). The ET was significantly longer in the AS group (318.5 ± 7.4 ms) and AR group (320.0 ± 4.6 ms), but significantly shorter in the MR group (289.0 ± 3.8 ms) compared to controls (305.3 ± 3.4 ms; all p <0.05). In ROC analyses of each group compared to controls, areas under the curve of UT, corrected (c)UT, ET and cET in the AS group, UT/ET ratio in the AR group, and PEP/UT ratio in the MR group were all >0.7. CONCLUSIONS: Multiple pulse wave parameters reflect VHD hemodynamics and may be useful for screening for the condition.

Clampless versus clamped coronary bypass grafting: does it make a difference?

PURPOSE OF REVIEW: The techniques of coronary artery bypass grafting (CABG) have evolved remarkably over the last two decades since the introduction of off-pump coronary artery bypass (OPCAB). This article focuses on the clinical outcomes of 'clampless' CABG strategies, that include OPCAB with a partial clamp, OPCAB with a proximal suture device, and aorta no-touch OPCAB. RECENT FINDINGS: Observational studies have shown the superiority of OPCAB for preventing strokes and pulmonary complications. Conversely, recent large-scale randomized controlled trials (RCTs) have been unable to demonstrate the benefits of OPCAB. Because of these differing results across numerous studies, the debate about the overall superiority of OPCAB versus on-pump CABG remains controversial. However, the literature regarding the OPCAB technique with minimized manipulation of the aorta suggests this has likely benefits, especially for high-risk patients. SUMMARY: Previous large RCTs did not focus on specific approaches of OPCAB or the importance of the experience of surgeons and institutions, and so further studies are needed. Observational studies and meta-analyses have indicated that improved outcomes can be achieved by applying specific OPCAB approaches according to each patient's characteristics.

Comparison of the Long-Term Outcomes of Mechanical and Bioprosthetic Aortic Valves　- A Propensity Score Analysis.

BACKGROUND: The aim of this study was to assess the long-term outcomes of aortic valve replacement (AVR) with either mechanical or bioprosthetic valves according to age at operation.Methods and Results:A total of 1,002 patients (527 mechanical valves and 475 bioprosthetic valves) undergoing first-time AVR were categorized according to age at operation: group Y, age <60 years; group M, age 60-69 years; and group O, age ≥70 years). Outcomes were compared on propensity score analysis (adjusted for 28 variables). Hazard ratio (HR) was calculated using the Cox regression model with adjustment for propensity score with bioprosthetic valve as a reference (HR=1). There were no significant differences in overall mortality between mechanical and bioprosthetic valves for all age groups. Valve-related mortality was significantly higher for mechanical valves in group O (HR, 2.53; P=0.02). Reoperation rate was significantly lower for mechanical valves in group Y (HR, 0.16; P<0.01) and group M (no events for mechanical valves). Although the rate of thromboembolic events was higher in mechanical valves in group Y (no events for tissue valves) and group M (HR, 9.05; P=0.03), there were no significant differences in bleeding events between all age groups. CONCLUSIONS: The type of prosthetic valve used in AVR does not significantly influence overall mortality.