Comparison of Minimally Invasive Direct Coronary Artery Bypass and Percutaneous Coronary Intervention Using Second-Generation Drug-Eluting Stents for Coronary Artery Disease　- Propensity Score-Matched Analysis.

BACKGROUND: Some studies comparing minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) have reported MIDCAB's superiority, but they did not investigate contemporary PCI with newer generation drug-eluting stents (DES). We compared clinical outcomes after MIDCAB with previously reported outcomes after PCI with second-generation DES.Methods and Results:We retrospectively reviewed the records of patients treated with MIDCAB. Baseline characteristics and clinical outcomes after MIDCAB were compared with those for left anterior descending artery disease treated via PCI. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), a composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke, and target vessel revascularization (TVR). A propensity score-matching (PSM) analysis was conducted to adjust for between-group differences in baseline characteristics. We analyzed 77 patients treated with MIDCAB and 2,206 treated with PCI. The MIDCAB group was older and had more severe coronary disease and a higher incidence of left ventricular dysfunction. Over a 3-year follow-up, the PCI group had favorable MACCE outcomes. After PSM, there were no between-group differences in MACCE (MIDCAB, 15.6% vs. PCI, 23.4%; hazard ratio [HR], 0.80; 95% CI: 0.38-1.68, P=0.548) or TVR (MIDCAB, 2.6% vs. PCI, 5.2%; HR, 0.51; 95% CI: 0.10-3.09, P=0.509). CONCLUSIONS: Clinical outcomes were similar between MIDCAB and PCI using second-generation DES over 3 years of follow-up.

Tricuspid Valve Replacement vs. Repair in Severe Tricuspid Regurgitation.

BACKGROUND: The aim of this study was to compare early and late outcomes of tricuspid valve replacement (TVR) and tricuspid valve repair (TVr) for severe tricuspid regurgitation (TR).Methods and Results:From 1994 to 2012, 360 patients (mean age, 58±13 years) with severe TR underwent TVR (n=97, 27%) or TVr (n=263, 73%). Among them, 282 patients (78%) had initial rheumatic etiology, and 307 patients (85%) had preoperative atrial fibrillation. The TVR group had higher total bilirubin, higher baseline central venous pressure, and higher incidence of previous cardiac operation. There was no difference in early mortality (TVR:TVr, 3.1%:3.4%, P=0.877). Ten-year overall survival (TVR:TVr, 72%:70%, P=0.532) and 10-year freedom from cardiac death (TVR:TVr, 76%:77%, P=0.715) were not significantly different between groups. After applying stabilized inverse probability of treatment weighting methods, there were still no significant differences in early mortality (P=0.293), overall survival (P=0.649) or freedom from cardiac death (P=0.870). Higher NYHA functional class, total bilirubin (>2 mg/dL), initial central venous pressure, and cardiopulmonary bypass time were independent predictors of early mortality. Older age, LV dysfunction (EF <40%), and hemoglobin <10 g/dL were independent predictors of late cardiac mortality. CONCLUSIONS: Compared with TVr, TVR had acceptable early and late outcomes in patients with severe TR. TVR can be considered as a valid option with acceptable clinical outcomes in patients who are not suitable candidates for TVr.

Role of mitral valve repair in infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Mitral valve reconstruction (MVP) is currently the standard treatment for degenerative mitral regurgitation (MR). However, when MR is due to infective endocarditis (IE) the range of pathophysiology present often makes any repair challenging. Hence, the authors' clinical experience of MVP to treat MR caused by IE was analyzed. METHODS: Between September 2004 and March 2011, a total of 26 patients (20 males, six females) who had been diagnosed with MR due to IE (single surgeon, retrospective review) were operated on. Among the 26 patients (17 active, nine healed; six Carpentier type I, 20 Carpentier type II), MVP was performed in 11 patients (42.3%), of which six were active cases and five were healed. All MVP procedures included ring annuloplasty. A variety of repair techniques was used, including triangular resection (n = 3), pericardial patch reconstruction (n = 4), commissuroplasty (n = 4), artificial chordoplasty (n = 1), chordae transfer (n = 2), and secondary chordae resection (n = 1). Six of 17 patients who had a pathology favorable for repair underwent valve replacement; the etiologies were underlying valvular disease (n = 2, rheumatic pathology), Child's group C liver cirrhosis (n = 1), second redo sternotomy (n = 1), multivalvular disease (n = 1), and critical medical condition (n = 1, septic shock). RESULTS: The mean follow up duration was 35.7 months (range: 0.1-84.9 months). Among the repair group, none of the patients showed residual MR on postoperative echocardiography. There were no early or late deaths, and no patient showed newly developed MR during the follow up. Among the replacement group, three patients died of noncardiac causes during the follow up (two early deaths and one late death). CONCLUSION: MVP for MR due to IE showed successful clinical outcomes. Valve replacement was performed in some patients with a repair-favorable pathology, after taking into consideration any comorbidities. Whilst standard repair techniques were sufficient, careful decision-making was the key to achieving excellent results for MVP.

Five-year experience with mini-volume priming in infants ≤5 kg: safety of significantly smaller transfusion volumes.

Reducing the cardiopulmonary bypass (CPB) priming volume in congenital cardiac surgery is important because it is associated with fewer transfusions. This retrospective study was designed to compare safety and transfusion volumes between the mini-volume priming (MP) and conventional priming (CP) methods. Between 2007 and 2012, congenital heart surgery using CPB was performed on 480 infants (≤5 kg): the MP method was used in 331 infants (MP group, 69.0%), and the CP method was used in 149 infants (CP group, 31.0%). In the MP group, narrow-caliber (3/16″) tubing was used, and the pump heads were vertically aligned to shorten the tubing lengths. The smallest possible oxygenators and hemofilters were used, and vacuum drainage was applied. Ultrafiltration was vigorously applied during CPB to avoid excessive hemodilution. The mean age and body weight of the patients were 48 ± 41 (0-306) days and 3.8 ± 0.8 (1.3-5.0) kg, respectively. The total priming and transfusion volumes during CPB were lower in the MP group than in the CP group (141 ± 24 mL vs. 292 ± 50 mL, P < 0.001, and 82 ± 40 mL vs. 162 ± 82 mL, P < 0.001, respectively). In the MP group, the smallest priming volume was 110 mL. However, there was no significant difference in the lowest hematocrit level during CPB between the two groups (22 ± 3% vs. 22 ± 3%, P = 0.724). The incidence of postoperative neurological complications was not significantly different between the MP and CP groups (1.8% vs. 2.7%, P = 0.509). After adjustment for the Risk Adjustment for Congenital Heart Surgery category, body surface area, and age, MP was not an independent risk factor of postoperative neurological complications or early mortality (P = 0.213 and P = 0.467, respectively). The MP method reduced the priming volume to approximately 140 mL without increasing the risk of morbidity or mortality in infants ≤5 kg. The total transfusion volume during CPB was reduced by 50% without compromising hematocrit levels. We recommend the use of mini-volume priming, which is a safe and effective method for reducing transfusion volumes.

Features and outcomes of focal intimal disruption in acute type B intramural haematoma.

OBJECTIVES: A focal intimal disruption (FID) is a risk factor for adverse aorta-related events in patients with acute type B intramural haematoma. This study evaluated the impact of FIDs on overall survival with a selective intervention strategy for large or growing FIDs. Additionally, this study evaluated the risk factors associated with the growth of FIDs. METHODS: This retrospective study included all consecutive patients admitted for acute type B intramural haematomas between November 2004 and April 2021. The primary outcome was overall survival. The secondary outcome was the cumulative incidence of composite aortic events and the growth of FIDs. The latter was calculated on centreline-reconstructed computed tomography images. RESULTS: A total of 105 patients were included. A total of 106 FIDs were identified in 73 patients (73/105, 69.5%). The 1- and 5-year cumulative incidence rates of composite aortic events were 36.2% and 39.2%, respectively. The 1- and 5-year overall survival was 93.3% and 81.5%, respectively. Initial maximal aortic diameter and large FIDs during acute phase were significant risk factors for composite aortic events, but not risk factors for overall survival. The early appearance interval of an FID was a significant risk factor for growth of an FID. CONCLUSIONS: With a selective intervention strategy for large or growing FIDs, the presence of large FIDs during the acute phase does not affect overall survival. The early appearance interval was associated with the growth of FIDs.

Comparative analysis of del Nido cardioplegia versus blood cardioplegia in isolate coronary artery bypass grafting.

BACKGROUND: This study examined the efficacy of del Nido cardioplegia compared with traditional blood cardioplegia in adult cardiac surgery for isolated coronary artery bypass grafting by evaluating the early postoperative outcomes. METHODS: A total of 119 patients who underwent isolated conventional coronary artery bypass grafting were enrolled and divided into two groups (del Nido cardioplegia group [n = 36] and blood cardioplegia group [n = 50]) based on the type of cardioplegia used. This study compared the preoperative characteristics, intraoperative data, and early postoperative outcomes. Further subgroup analyses were conducted for high-risk patient groups. RESULTS: The 30-day mortality and morbidity rates were not significantly different between groups. The del Nido cardioplegia group exhibited advantageous myocardial protection outcomes, demonstrated by a significantly smaller rise in Troponin I levels post-surgery (2.8 [-0.4; 4.2] vs. 4.5 [2.9; 7.4] ng/mL, p = 0.004) and fewer defibrillation attempts during weaning off of cardiopulmonary bypass (0.0 ± 0.2 vs. 0.4 ± 1.1 times, p = 0.011) when compared to the blood cardioplegia group. Additionally, the del Nido group achieved a reduction in surgery duration, as evidenced by the reduced aortic cross-clamping time (64.0 [55.5; 75.5] vs. 77.5 [65.0; 91.0] min, p = 0.001) and total operative time (287.5 [270.0; 305.0] vs. 315.0 [285.0; 365.0] min, p = 0.008). Subgroup analyses consistently demonstrated that the del Nido cardioplegia group had a significantly smaller postoperative increase in Troponin I levels across all subgroups (p < 0.05). CONCLUSIONS: del Nido cardioplegia provided myocardial protection and favorable early postoperative outcomes compared to blood cardioplegia, making it a viable option for conventional coronary artery bypass grafting. Establishing a consensus on the protocol for Del Nido cardioplegia administration in adult surgeries is needed.

Thrombocytopenia after Aortic Valve Replacement Using Sutureless Valves.

Background: Sutureless valves are widely used in aortic valve replacement surgery, with Perceval valves and Intuity valves being particularly prominent. However, concerns have been raised about postoperative thrombocytopenia with Perceval valves (Corcym, UK). We conducted a comparative analysis with the Intuity valve (Edwards Lifesciences, USA), and assessed how thrombocytopenia affected patient and transfusion outcomes. Methods: Among 595 patients who underwent aortic valve replacement from June 2016 to March 2023, sutureless valves were used in 53 (Perceval: n=23; Intuity: n=30). Platelet counts were monitored during hospitalization and outpatient visits. Daily platelet count changes were compared between groups, and the results from patients who underwent procedures using Carpentier Edwards Perimount Magna valves were used as a reference group. Results: Compared to the Intuity group, the Perceval group showed a significantly higher amount of platelet transfusion (5.48±1.64 packs vs. 0.60±0.44 packs, p=0.008). During the postoperative period, severe thrombocytopenia (<50,000/µL) was significantly more prevalent in the Perceval group (56.5%, n=13) than in the Intuity group (6.7%, n=2). After initial postoperative depletion, daily platelet counts increased, with significant differences observed in the extent of improvement between the Perceval and Intuity groups (p<0.001). However, there was no significant difference in early mortality or the incidence of neurological complications between the 2 groups. Conclusion: The severity of postoperative thrombocytopenia differed significantly between the Perceval and Intuity valves. The Perceval group showed a significantly higher prevalence of severe thrombocytopenia and higher platelet transfusion volumes. However, thrombocytopenia gradually recovered during the postoperative period in both groups, and the early outcomes were similar in both groups.

Impact of pericardial calcification on early postoperative outcomes after pericardiectomy: a retrospective observational study.

BACKGROUND: Owing to the lack of understanding of the clinical significance of pericardial calcification during pericardiectomy, whether pericardial calcification should be considered when determining the optimal timing for pericardiectomy is debatable. We aimed to investigate the effect of pericardial calcification on early postoperative outcomes in patients who underwent pericardiectomy for constrictive pericarditis. METHODS: Altogether, 44 patients who underwent pericardiectomy for constrictive pericarditis were enrolled. After excluding three patients who underwent concurrent surgeries, a total of 41 patients were categorized into two groups based on the presence of pericardial calcification as determined by preoperative computed tomography and pathological examination. Preoperative clinical and imaging characteristics, intraoperative data, and early postoperative outcomes were compared between the two groups. A multivariable analysis was performed to identify the factors associated with postoperative complications. RESULTS: The group with and without PC comprised 21 and 20 patients, respectively. No significant differences were observed in 30-day mortality (n = 1 [5%]) in the group with pericardial calcification and no mortality in the group without pericardial calcification (p > 0.999). Other early postoperative outcome variables did not demonstrate any significant differences between the two groups. However, the use of cardiopulmonary bypass was associated with postoperative complications (p < 0.009, odds ratio: 63.5, 95% confidence interval: 5.13-3400). CONCLUSIONS: Pericardial calcification did not significantly affect the postoperative outcomes after pericardiectomy. Further comprehensive studies, including those with larger sample sizes and longitudinal designs, are necessary to determine whether pericardial calcification can significantly influence the timing of surgical intervention.

Acute type A aortic dissection features and outcomes in octogenarians: a propensity score analysis.

OBJECTIVES: The clinical characteristics and early outcomes of surgical repair in octogenarians with acute type A aortic dissection were compared with those in nonoctogenarians. METHODS: All patients who underwent emergency surgical repair for acute type A aortic dissection in our institution between 2003 and 2022 were included in this study. The patients were divided into an octogenarian group and a nonoctogenarian group. The patients in the 2 groups were propensity score matched at a ratio of 1:1. Before matching, the baseline characteristics were compared between 2 groups. The major complication and 30-day mortality rates were compared in the matched population. RESULTS: A total of 495 patients were screened, and 471 were included in the analysis, with 48 in the octogenarian group and 423 in the nonoctogenarian group. Before matching, DeBakey type II dissection was significantly more prevalent in the octogenarians (42% vs 14% in the octogenarians and nonoctogenarians, respectively, P < 0.001). Additionally, intramural haematomas (39.6% vs 14.4%, P < 0.001) were more prevalent in the octogenarians. However, severe aortic regurgitation (4.2% vs 15.4%, P = 0.046) and root enlargement (0% vs 13.7%, P = 0.009) were less prevalent in the octogenarians. After matching (36 pairs), the incidence of postoperative delirium was higher in the octogenarians (56% vs 25%, P = 0.027). However, there were no significant differences in 30-day and in-hospital mortality rates, intensive care unit stay or major complications, including stroke, paraplegia, respiratory complications, mediastinitis and haemodialysis. CONCLUSIONS: The octogenarians with acute type A aortic dissection had higher incidences of DeBakey type II dissection and intramural haematomas and lower incidences of severe aortic regurgitation and aortic root enlargement than the nonoctogenarians. Being an octogenarian was not associated with an increased risk of early major complications or mortality after surgery for acute type A aortic dissection.

Influence of Preoperative COVID-19 Vaccination on Outcomes After Coronary Artery Bypass Grafting-A Propensity Score-Matched Analysis.

BACKGROUND: Reports of intravascular thrombosis and cardiac complications have raised concerns about the safety of COVID-19 vaccinations, particularly in patients with high cardiovascular risk. Herein, we aimed to analyze the impact of preoperative COVID-19 vaccination on outcomes after coronary artery bypass grafting (CABG). METHODS AND RESULTS: Among 520 patients who underwent isolated CABG from 2020 to 2022, 481 patients (mean±SD age: 67±11 years, 86 women) whose COVID-19 vaccination status could be confirmed were included. A total of 249 patients who had not received any COVID-19 vaccine before CABG (never vaccinated group) and 214 patients who had completed primary vaccination (fully vaccinated group) were subjected to 1:1 propensity score matching, and 156 pairs of patients were matched. There was no significant difference in early mortality between the 2 groups after matching. After matching, overall survival (P=0.930) and major adverse cardiovascular and cerebrovascular event-free survival (P=0.636) did not differ between the 2 groups. One-year graft patency also did not differ significantly between the 2 groups; all patent grafts in 85/104 patients (82%) and 62/73 patients (85%) in the never vaccinated and fully vaccinated groups, respectively (P=0.685). Subgroup analysis showed equivalent overall and major adverse cardiovascular and cerebrovascular event-free survival among AstraZeneca and Pfizer vaccine recipients and between those with ≤30 days versus >30 days from vaccination to CABG. CONCLUSIONS: Despite the very high cardiovascular risk for patients undergoing CABG, COVID-19 vaccination did not affect major outcomes after CABG. Therefore, there is no reason for patients with coronary artery disease requiring CABG to avoid preoperative COVID-19 vaccination.

Impact of patient-prosthesis mismatch in the aortic position: twenty-year experience with Korean patients.

BACKGROUND AND AIM OF THE STUDY: The impact of patient-prosthesis mismatch (PPM) on clinical outcomes following aortic valve replacement (AVR) remains controversial. The study aim was to evaluate the impact of PPM on long-term clinical outcomes following AVR. METHODS: Between January 1987 and September 2007, a total of 198 consecutive patients (mean age 59.6 +/- 10.5 years; range: 31-85 years) underwent isolated AVR for pure aortic stenosis at the authors' institutions. PPM was defined as an indexed effective orifice area (EOAI) < 0.85 cm2/m2, and was present in 45 patients (22.7%). The mean follow up duration was 102.6 +/- 71.6 months (maximum 270 months). RESULTS: The early mortality was 1.5% (n = 3). The late mortality was similar in both the PPM and non-PPM groups (4.4% versus 4.7%; p = 0.950). The left ventricular mass index during follow up was higher in the PPM group (128.5 +/- 36.1 versus 114.5 +/- 39.1 g/m2, p = 0.037). Freedom from cardiac-related mortality at 15 years was 86.5 +/- 4.3% in the non-PPM group, and 92.9 +/- 4.9% in the PPM group (p = 0.282). Freedom from heart failure events at 15 years was 74.6 +/- 6.6% in the non-PPM group and 61.6 +/- 8.5% in the PPM group (p = 0.028). Predictors of heart failure events were female gender (p = 0.041, hazards ratio (HR) = 2.5, 95% confidence interval (CI) = 1.1-5.9) and PPM (p = 0.001, HR = 5.1, 95% CI = 1.9-13.7). CONCLUSION: In AVR patients with pure aortic stenosis, PPM, when defined by the threshold value of EOAI < 0.85 cm2/m2, was not associated with differences in cardiac-related mortality. However, PPM was related to an increased incidence of postoperative heart failure events.

Relationship between morphologic features of myocardial tissue and left ventricular function in patients with aortic valve disease and left ventricular hypertrophy.

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate the correlation of myocardial fibrosis with myocardial remodeling and clinical outcome of aortic valve replacement (AVR) in patients with aortic stenosis and left ventricular (LV) hypertrophy. METHODS: Between 2007 and 2010, a total of 43 patients (23 males, 20 females; mean age 65.5 +/- 10.6 years; range: 33-84 years) underwent AVR at the authors' institution. During surgery, specimens (10 mm3) were obtained from the LV outflow tract and stained with Masson's trichrome. The fibrosis fraction (FF) was quantified. The mean follow up duration was 18.8 +/- 12.2 months (range: 0-46 months). Patients were allocated to either of two groups: the lower fibrosis (LF) group (n = 24) with FF < 5%, and the higher fibrosis (HF) group (n = 19) with FF > or = 5%. RESULTS: There were no significant differences between the two groups in terms of preoperative NYHA functional class and complications. In total, 33 patients (19 LF and 14 HF) were followed up for at least six months. The preoperative LV mass index (LVMI) and LV ejection fraction (LVEF) were not significantly different between the two groups (p = 0.805 and p = 0.377, respectively). At the last follow up examination the LVMI showed a significant inter-group difference (LF group 111.4 +/- 23.2 g/m2; HF group 91.9 +/- 21.5 g/m2; p = 0.005), but the LVEF did not differ significantly between groups (p = 0.457). There was one early (non-cardiac) death in the LF group, and one early death and one late death (both cardiac-related) in the HF group. CONCLUSION: In patients with aortic stenosis, a higher LVMI was not related to more severe myocardial fibrosis, and LV mass regression after AVR was not influenced by the severity of the myocardial fibrosis. Rather, cardiac-related death might be related to a highly fibrotic heart.

De Vega annuloplasty for functional tricupsid regurgitation: concept of tricuspid valve orifice index to optimize tricuspid valve annular reduction.

We evaluated long-term results of De Vega annuloplasty measured by cylindrical sizers for functional tricuspid regurgitation (FTR) and analyzed the impact of measured annular size on the late recurrence of tricuspid valve regurgitation. Between 2001 and 2011, 177 patients (57.9±10.5 yr) underwent De Vega annuloplasty for FTR. Three cylindrical sizers (actual diameters of 29.5, 31.5, and 33.5 mm) were used to reproducibly reduce the tricuspid annulus. Long-term outcomes were evaluated and risk factor analyses for the recurrence of FTR ≥3+ were performed. Measured annular diameter indexed by patient's body surface area was included in the analyses as a possible risk factor. Operative mortality occurred in 8 patients (4.5%). Ten-year overall and cardiac death-free survivals were 80.5% and 90.8%, respectively. Five and 10-yr freedom rates from recurrent FTR were 96.5% and 93.1%, respectively. Cox proportional hazard model revealed that higher indexed annular size was the only risk factor for the recurrence of FTR (P=0.006). A minimal P value approach demonstrated that indexed annular diameter of 22.5 mm/m(2) was a cut-off value predicting the recurrence of FTR. De Vega annuloplasty for FTR results in low rates of recurrent FTR in the long-term. Tricuspid annulus should be reduced appropriately considering patients' body size to prevent recurrent FTR.

A Two-Step Approach to Overcoming Data Imbalance in the Development of an Electrocardiography Data Quality Assessment Algorithm: A Real-World Data Challenge.

Continuously acquired biosignals from patient monitors contain significant amounts of unusable data. During the development of a decision support system based on continuously acquired biosignals, we developed machine and deep learning algorithms to automatically classify the quality of ECG data. A total of 31,127 twenty-s ECG segments of 250 Hz were used as the training/validation dataset. Data quality was categorized into three classes: acceptable, unacceptable, and uncertain. In the training/validation dataset, 29,606 segments (95%) were in the acceptable class. Two one-step, three-class approaches and two two-step binary sequential approaches were developed using random forest (RF) and two-dimensional convolutional neural network (2D CNN) classifiers. Four approaches were tested on 9779 test samples from another hospital. On the test dataset, the two-step 2D CNN approach showed the best overall accuracy (0.85), and the one-step, three-class 2D CNN approach showed the worst overall accuracy (0.54). The most important parameter, precision in the acceptable class, was greater than 0.9 for all approaches, but recall in the acceptable class was better for the two-step approaches: one-step (0.77) vs. two-step RF (0.89) and one-step (0.51) vs. two-step 2D CNN (0.94) (p < 0.001 for both comparisons). For the ECG quality classification, where substantial data imbalance exists, the 2-step approaches showed more robust performance than the one-step approach. This algorithm can be used as a preprocessing step in artificial intelligence research using continuously acquired biosignals.

Elevated troponin I is associated with a worse long-term prognosis in patients undergoing beating-heart coronary surgery.

OBJECTIVES: The impacts of elevated troponin I levels after coronary artery bypass grafting (CABG) on long-term outcomes were investigated. METHODS: A total of 996 patients who underwent elective isolated CABG for stable or unstable angina were enrolled. Patients were divided into higher and lower groups based on 80th percentile postoperative peak troponin I (ppTnI) levels. The relationship between ppTnI and long-term clinical outcomes was analysed. RESULTS: The median ppTnI was 1.55 (2.74) ng/ml and was significantly higher in the conventional CABG subgroup than in the beating-heart CABG subgroup: 4.04 (4.71) vs 1.24 (1.99) ng/ml, P < 0.001. The 80th percentile of ppTnI was 3.3 ng/ml in the beating-heart CABG subgroup and 8.9 ng/ml in the conventional CABG subgroup. In the conventional CABG subgroup (n = 150), 10-year overall survival showed no significant difference between the higher (≥8.9 ng/ml) and lower (<8.9 ng/ml) ppTnI groups: 71% (10%) vs 76% (5%), P = 0.316. However, the beating-heart CABG subgroup (n = 846) showed significantly worse 10-year overall survival in the higher ppTnI group (≥3.3 ng/ml) than in the lower ppTnI group (<3.3 ng/ml): 64% (6%) vs 73% (3%), P = 0.010. In the beating-heart CABG subgroup, multivariable analysis showed that ppTnI exceeding the 80th percentile was a risk factor for overall death (hazard ratio: 1.505, 95% confidence interval: 1.019-2.225, P = 0.040). CONCLUSIONS: Higher ppTnI over the 80th percentile was associated with worse long-term survival in beating-heart CABG, but not in conventional CABG.

Improved clinical outcomes following introduction of an attending intensivist for patients admitted to the cardiac surgical intensive care unit after valvular heart surgery: a single-center experience.

Background: Although numerous studies have documented the improved clinical outcomes of patients undergoing cardiac surgery following introduction of attending intensivist, most of these studies included heterogeneous patient populations. We aimed to investigate the impact of an attending intensivist on the clinical outcomes of patients admitted to the cardiac surgical intensive care unit (CSICU) following valvular heart surgery. Methods: Patients who underwent valvular heart surgery between January 2007 and December 2012 (control group, n=337) were propensity matched (1:1) between January 2013 and June 2017 (intensivist group, n=407). Results: During the propensity score matching analysis, 285 patients were extracted from each group. Patients in the intensivist group underwent mechanical ventilation for a significantly shorter time than those in the control group (21.8±69.8 vs. 39.2±115.3 hours, P=0.021). More patients were extubated within 6 hours in the intensivist group than in the control group (53.7% vs. 42.8%, P=0.015). The incidence of ventilator-associated pneumonia (1.4% vs. 4.9%, P=0.031), cardiac arrest due to cardiac tamponade associated with post-cardiotomy bleeding (0.4% vs. 3.9%, P=0.002), and acute kidney injury (2.8% vs. 7.7%, P=0.011) in the intensivist group was significantly lower than that in the control group. The 30-day mortality rate of the intensivist group was significantly lower than that of the control group (2.1% vs. 6.7%, P=0.015). Conclusions: Critical care provided in the CSICU staffed by an attending intensivist is associated with a lower 30-day mortality rate and reduced incidence of postoperative complications.

Long-term patency of bilateral internal thoracic artery Y composite coronary artery bypass grafts-determinants and impact on survival.

Background: Bilateral internal thoracic artery Y-composite grafting with sequential anastomoses is a well-established strategy for multi-arterial coronary artery bypass grafting. This study investigated the factors affecting long-term patency of bilateral internal thoracic artery Y-composite grafts and their influence on survival. Methods: Patients who underwent coronary artery bypass grafting using bilateral internal thoracic artery Y-composite grafts due to triple-vessel disease were included. In total, 415 cases (2003-2020) with at least 1 postoperative coronary computed tomography or angiography examination were enrolled. Through a retrospective review of medical records and computed tomography, risk factors for graft events (string sign or occlusion) were analysed, and the influence of string sign or occlusion in the initial postoperative computed tomography on long-term survival was evaluated. Results: Patients' mean age was 66±9 years and 324 were male (78%). The mean number of anastomoses from bilateral internal thoracic artery grafts was 4.0±0.9. The mean follow-up duration was 8.0±4.0 years (interquartile range: 4.8-11.5 years). Beating-heart surgery negatively affected the patency of grafts to the left circumflex and right coronary artery territories (P=0.015 and P=0.030, respectively), but in the left anterior descending territory, the graft patency did not differ (P=0.053). Non-severe (<90%) native-vessel stenosis was a risk factor for poor patency in the left anterior descending, left circumflex, and right coronary artery territories (P<0.001 for all). Twenty-four of the 104 nonvisible or narrowed grafts (23%) on early imaging later became widely patent. Occlusion of the grafts or the string sign within postoperative 1 year did not have a negative impact on long-term survival (P=0.421). Conclusions: The patency rate was suboptimal in case of non-severe target-vessel stenosis (<90%). The beating-heart technique may negatively influence the patency of anastomoses to the left circumflex and right coronary artery territories. Compromised graft patency observed on initial computed tomography did not lead to worse survival.

Fate of remaining dissected aorta after descending thoracic or thoracoabdominal aorta replacement for chronic dissection.

OBJECTIVES: After performing descending thoracic or thoraco-abdominal aorta replacement for chronic aortic dissection, the fate of the remaining dissected aorta, without significant enlargement, is not well known. This study aimed to investigate the changes in the remaining aorta and the risk factors for late composite aortic events. METHODS: In 98 patients with chronic type A or B aortic dissection who underwent descending thoracic or thoraco-abdominal aorta replacement, the immediate postoperative and last follow-up computed tomography scans were reviewed. Aortic area-derived diameter was measured using the centreline reconstruction method at the levels of the 10 zones of the aorta and iliac arteries. The incidence of and risk factors for late composite aortic events (aortic death, rupture, reoperation, last follow-up aortic area-derived diameter >60 mm) were analysed. RESULTS: The median follow-up and computed tomography follow-up durations were 88.5 and 63.7 months, respectively. Nine late deaths occurred. The median growth rate of the remaining aorta was the greatest in the dissected infrarenal abdominal aorta at 0.8 mm/year. Of 16 late composite aortic events, the majority (2 ruptures and 8 reoperations) occurred in the distal contiguous segment. The 5- and 10-year cumulative incidence of events in the distal contiguous segment were 4.9% and 16.1%, respectively. Young age and Marfan syndrome were significant risk factors. CONCLUSIONS: Late composite aortic events were not negligible, especially in the distal contiguous segment. In young or Marfan syndrome patients, a greater distal extent of replacement may have to be considered at experienced aortic centres.

Robot-Assisted Repair of Atrial Septal Defect: A Comparison of Beating and Non-Beating Heart Surgery.

BACKGROUND: Robot-assisted repair of atrial septal defect (ASD) can be performed under either beating-heart or non-beating-heart conditions. However, the risk of cerebral air embolism (i.e., stroke) is a concern in the beating-heart approach. This study aimed to compare the outcomes of beating- and non-beating-heart approaches in robot-assisted ASD repair. METHODS: From 2010 to 2019, a total of 45 patients (mean age, 43.4±14.6 years; range, 19-79 years) underwent ASD repair using the da Vinci robotic surgical system. Twenty-seven of these cases were performed on a beating heart (beating-heart group, n=27) and the other cases were performed on an arrested or fibrillating heart (non-beating-heart group, n=18). Cardiopulmonary bypass (CPB) was achieved via cannulation of the femoral vessels and the right internal jugular vein in all patients. RESULTS: Complete ASD closure was verified using intraoperative transesophageal echocardiography in all patients. Conversion to open surgery was not performed in any cases, and there were no major complications. All patients recovered from anesthesia without any immediate postoperative neurologic symptoms. In a subgroup analysis of isolated ASD patch repair (beating-heart group: n=22 vs. non-beating-heart group: n=5), the operation time and CPB time were shorter in the beating-heart group (234±38 vs. 253±29 minutes, p=0.133 and 113±28 vs. 143±29 minutes, p=0.034, respectively). CONCLUSION: Robot-assisted ASD repair can be safely performed with the beating-heart approach. No additional risk in terms of cerebral embolism was found in the beating-heart group.

Changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection.

OBJECTIVES: The aim of this study was to evaluate changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection (ABAD). METHODS: Medically treated patients with uncomplicated ABAD between September 2004 and January 2020 were retrospectively reviewed. Diameters of 6 different sites in the descending aorta were measured and aortic growth rate was calculated according to the time interval. Factors associated with aneurysmal changes were also investigated. RESULTS: This study enrolled a total of 105 patients who underwent >2 serial computed tomography with a mean follow-up duration of 35.4 (12.1-77.4) months. The mean overall growth rates of the proximal descending thoracic aorta (DTA), mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA and maximal abdominal aorta were 0.6 (1.9), 2.9 (5.2), 2.1 (4.0), 1.2 (2.2), 3.3 (5.6) and 1.4 (2.5) mm/year, respectively. The growth rate was higher at the early stage. It decreased over time. Growth rates of proximal DTA, mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA, and maximal abdominal aorta within 3 months after dissection were 1.3 (9.6), 12.6 (18.2), 7.6 (11.7), 5.9 (7.5), 16.7 (19.8) and 6.8 (8.9) mm/year, respectively. More than 2 years later, they were 0.2 (0.6), 1.6 (1.6), 1.2 (1.3), 0.9 (1.4), 1.7 (1.9) and 1.2 (1.7) mm/year, respectively. Factors associated with aneurysmal changes after uncomplicated ABAD included an elliptical true lumen (odds ratio = 3.16; 95% confidence interval: 1.19-8.41; P = 0.021) and a proximal entry >10 mm (odds ratio = 3.08; 95% confidence interval: 1.09-8.69; P = 0.034) on initial computed tomography imaging. CONCLUSIONS: The aortic growth rate was higher immediately after uncomplicated ABAD but declined eventually. Patients with an elliptical true lumen and a large proximal entry might be good candidates for early endovascular intervention after uncomplicated ABAD.