Thick endothelialization of the self-expandable valve causes delayed coronary obstruction.

Delayed coronary obstruction is a rare complication occurring after transcatheter aortic valve replacement (TAVR). Although TAVR has become popular, in some cases, the therapeutic strategy should be carefully selected depending on the patient's anatomical and/or functional restrictions. We report a rare case of delayed coronary obstruction in which coronary obstruction was caused by thick endothelialization of the nitinol frame of the prosthetic valve. A 79-year-old female who had undergone TAVR 4 months before presented with mild chest pain and was admitted to our institution. Computed tomography and coronary angiography revealed that the space from the sinus of Valsalva to the nitinol frame was narrow and separated from the inside of the nitinol frame because of critical endothelialization. Therefore, an emergency surgical aortic valve replacement was performed. The patient had an uneventful postoperative course and was discharged 20 days postoperatively without any complications.

Clinical Outcomes of Left Ventricular Assist Device Pump Infection.

Few studies have focused on the clinical outcomes and risk factors of left ventricular assist device (LVAD) pump infection, and no standard treatment for LVAD pump infection has been established. Therefore, we used a therapeutic flowchart to manage LVAD pump infections. We retrospectively evaluated 220 patients who underwent continuous-flow LVAD implantation between January 2005 and March 2021 at Osaka University, Japan. First, we performed wound debridement, negative-pressure wound therapy, antibiotic treatment, and omental flap transposition. Subsequently, we administered conservative treatment, scheduled implantable LVAD exchange, or emergent removal of the implantable LVAD and exchange for extracorporeal LVAD or percutaneous LVAD (IMPELLA). Pump infections occurred in 32 patients. The survival rates of patients with pump infections during LVAD support were 93%, 74%, and 61% at 180 days, 1 year, and 2 years after LVAD pump infection, respectively. Fifteen patients underwent successful heart transplantation. Bridge-to-bridge surgery, preoperative use of venoarterial extracorporeal membrane oxygenation or percutaneous LVAD, high lactate dehydrogenase levels, and driveline infection were significantly associated with pump infection. Our study reveals that poor preoperative condition and driveline infection were significant risk factors for LVAD pump infection.

Laminin-221 Enhances Therapeutic Effects of Human-Induced Pluripotent Stem Cell-Derived 3-Dimensional Engineered Cardiac Tissue Transplantation in a Rat Ischemic Cardiomyopathy Model.

Background Extracellular matrix, especially laminin-221, may play crucial roles in viability and survival of human-induced pluripotent stem cell-derived cardiomyocytes (hiPS-CMs) after in vivo transplant. Then, we hypothesized laminin-221 may have an adjuvant effect on therapeutic efficacy by enhancing cell viability and survival after transplantation of 3-dimensional engineered cardiac tissue (ECT) to a rat model of myocardial infarction. Methods and Results In vitro study indicates the impacts of laminin-221 on hiPS-CMs were analyzed on the basis of mechanical function, mitochondrial function, and tolerance to hypoxia. We constructed 3-dimensional ECT containing hiPS-CMs and fibrin gel conjugated with laminin-221. Heart function and in vivo behavior were assessed after engraftment of 3-dimensional ECT (laminin-conjugated ECT, n=10; ECT, n=10; control, n=10) in a rat model of myocardial infarction. In vitro assessment indicated that laminin-221 improves systolic velocity, diastolic velocity, and maximum capacity of oxidative metabolism of hiPS-CMs. Cell viability and lactate dehydrogenase production revealed that laminin-221 improved tolerance to hypoxia. Furthermore, analysis of mRNA expression revealed that antiapoptotic genes were upregulated in the laminin group under hypoxic conditions. Left ventricular ejection fraction of the laminin-conjugated ECT group was significantly better than that of other groups 4 weeks after transplantation. Laminin-conjugated ECT transplantation was associated with significant improvements in expression levels of rat vascular endothelial growth factor. In early assessments, cell survival was also improved in laminin-conjugated ECTs compared with ECT transplantation without laminin-221. Conclusions In vitro laminin-221 enhanced mechanical and metabolic function of hiPS-CMs and improved the therapeutic impact of 3-dimensional ECT in a rat ischemic cardiomyopathy model. These findings suggest that adjuvant laminin-221 may provide a clinical benefit to hiPS-CM constructs.

Surgical Results for Infective Endocarditis Complicated With Cardiogenic Shock.

BACKGROUND: Infective endocarditis remains associated with substantial mortality and morbidity rates, and the presence of acute heart failure (AHF) compromises clinical results after valve surgery; however, little is known in cardiogenic shock (CGS) patients. This study evaluated the clinical results and risk of mortality in CGS patients after valve surgery.Methods and Results:This study enrolled 585 patients who underwent valve surgery for active endocarditis at 14 institutions between 2009 and 2017. Of these patients, 69 (12%) were in CGS, which was defined as systolic blood pressure <80 mmHg and severe pulmonary congestion, requiring mechanical ventilation and/or mechanical circulatory support, preoperatively. The predictors of CGS were analyzed, and clinical results of patients with non-CGS AHF (n=215) were evaluated and compared.Staphylococcus aureusinfection (odds ratio [OR] 2.19; P=0.044), double valve involvement (OR 3.37; P=0.003), and larger vegetation (OR 1.05; P=0.036) were risk factors for CGS. Hospital mortality occurred in 27 (13%) non-CGS AHF patients and in 15 (22%) CGS patients (P=0.079). Overall survival at 1 and 5 years in CGS patients was 76% and 69%, respectively, and there were no significant differences in overall survival compared with non-CGS AHF patients (P=1.000). CONCLUSIONS: Clinical results after valve surgery in CGS patients remain challenging; however, mid-term results were equivalent to those of non-CGS AHF patients.

Emergency valve surgery improves clinical results in patients with infective endocarditis complicated with acute cerebral infarction: analysis using propensity score matching†.

OBJECTIVES: To date, the optimal timing for patients with infective endocarditis (IE) with acute cerebral infarction (CI) to undergo valve surgery is unknown. Although some previous studies have reported that early valve surgery for IE patients within 1 or 2 weeks after CI could be performed safely, an initial strategy has not been identified because of the unmatched cohorts in previous studies. This study aimed to assess the feasibility and safety of early surgery within a few days after cerebral infarction by using propensity score matching. METHODS: Between 2009 and 2017, 585 patients underwent valve surgery for patients with active IE at 14 institutions. Among these, 152 had preoperative acute CI. Early surgery was defined as surgery within 3 days after the diagnosis of CI. Of these 152 patients, 67 underwent early valve surgery (early group), whereas 85 underwent delayed valve surgery (delayed group). Of the patients, 45 in each group were analysed using propensity score matching. The primary outcome was in-hospital death after valve surgery, and secondary outcomes included neurological complications. We compared the clinical results of these matched patients. RESULTS: Hospital mortality was lower in the early group (2% vs 16%, P = 0.058). The rate of postoperative intracranial haemorrhage in the early and delayed groups was 4% in both groups. The postoperative modified Rankin scale was not significantly different [early group: 0 (0-2); delayed group: 0 (0-2)]. Incidence of neurological deterioration did not differ significantly between the groups. The survival rates after the first discharge at 1, 3 and 5 years after valve operation were 100%, 97% and 97% in the early group and 91%, 83% and 80% in the delayed group, respectively (P = 0.029). CONCLUSIONS: Early valve surgery for patients with IE within 3 days after a CI measuring <2 cm in size improved clinical results without increasing the incidence of postoperative neurological complications.

Right Atrial Pressure Waveform Predicts Right Ventricular Failure After Left Ventricular Assist Device Implantation.

BACKGROUND: Right ventricular failure (RVF) is one of the major adverse events after left ventricular assist device (LVAD) implantation. Right ventricle (RV) distensibility plays a key role in the preload reserve capability and in RV ejection through the Frank-Starling mechanism. However, there are no studies focusing on the relationship between RVF and RV distensibility. METHODS: Between 2013 and 2017, 115 consecutive patients underwent continuous-flow LVAD implantation at Osaka University Hospital. Of these, 71 who recorded preoperative right atrial pressure waveform were included. We assessed RV distensibility and the incidence and risk factors for RVF, which was defined as the requirement for a right ventricular assist device or 14 or more consecutive days of inotropic support required postoperatively, or both. A distensible RV was interpreted if the right atrial pressure waveform showed a dominant "Y" descent that was equal to or deeper than the "X" descent. RESULTS: Thirty-two patients (45%) had RVF after LVAD implantation. Among the patients with RVF, 4 required right ventricular assist device support and all of them had a less distensible RV. Multivariate analysis revealed that a less distensible RV (odds ratio 10.5, 95% confidence interval, 1.75 to 63.5, P = .003) and an elevated level of central venous pressure/pulmonary capillary wedge pressure (odds ratio 2.02, 95% confidence interval, 1.20 to 3.40, P = .002) were independent risk factors for RVF after LVAD implantation. CONCLUSIONS: Less distensible RV and elevated central venous pressure/pulmonary capillary wedge pressure level were significant risks for RVF after LVAD implantation. This result suggested that analysis of not only the hemodynamic numbers but also the pattern of waveforms are important to assess risk for RVF in LVAD candidates.

Surgery-first treatment improves clinical results in infective endocarditis complicated with disseminated intravascular coagulation†.

OBJECTIVES: Infective endocarditis (IE) is a critical infection with a high mortality rate, and it usually causes sepsis. Though disseminated intravascular coagulation (DIC) sometimes occurs in IE patients, no definitive treatment strategy for IE patients with DIC as a complication exists. Therefore, we evaluated the prevalence, surgical results and treatment strategy for IE complicated with DIC. METHODS: Between 2009 and 2017, a total of 585 patients undergoing valve surgery for active IE were enrolled at 14 institutions, of whom 116 (20%) had DIC as a complication. For further evaluation, we divided DIC patients into medical treatment-first (n = 45, group M) and valve surgery-first (n = 51, group S) groups after excluding 20 patients with intracranial haemorrhage. RESULTS: The overall survival rates at 1 and 5 years were 91% and 85% in the non-DIC group and 65% and 55% in the DIC group, respectively (P < 0.001). Recurrence-free survival rates at 1 and 5 years were 99% and 95% in the non-DIC group and 94% and 74% in the DIC group, respectively (P < 0.001). The overall survival rates at 1 and 5 years were 77% and 64% in group S and 51% and 46% in group M, respectively (P = 0.032). Multivariable analysis revealed that 'medical treatment first' was an exclusive independent risk factor [hazards ratio 2.26 (1.13-4.75), P = 0.024] for overall mortality. CONCLUSIONS: Mortality and IE recurrence were statistically significantly higher in DIC patients. Valve surgery should not be delayed because most patients proceeding with medical treatment eventually require emergency surgery and their clinical outcomes are worse than those of patients undergoing early surgery.

Results of surgical management of infective endocarditis associated with Staphylococcus aureus.

OBJECTIVES: Staphylococcus aureus (SA) is a leading cause of infective endocarditis (IE), and such cases are on the rise. Our objective was to evaluate the clinical outcomes of surgical intervention in patients with SA-associated IE and to identify the factors associated with outcomes. METHODS: Between 2009 and 2017, 585 patients underwent valve surgery for definitive left-sided IE at 14 affiliated hospitals. Their medical records were retrospectively reviewed, and the preoperative variables and clinical results of patients with (n = 117) or without SA infection (n = 468) were compared. RESULTS: The SA group had a more critical preoperative condition with higher rates of chronic haemodialysis, preoperative embolic events and preoperative inflammation levels, as well as worse renal function. In-hospital mortality was 20% and 7% in the patients with or without SA infection, respectively. The overall survival rate at 1 year and 5 years was 72% and 62% in the SA group, and 88% and 81% in the non-SA group, respectively (P < 0.001). The Cox hazard analysis revealed that methicillin-resistant SA infection was an independent risk factor for overall mortality in the SA group. The rate of freedom from recurrence of endocarditis at 1 year and 5 years was 95% and 90% in the SA group and 96% and 92% in the non-SA group, respectively (P = 0.43). CONCLUSIONS: The short- and mid-term outcomes after valve surgery for active IE in patients with SA are still challenging. Methicillin-resistant SA infection is an independent predictor of mid-term mortality.

Risk of stroke early after implantation of a left ventricular assist device.

OBJECTIVE: Stroke is one of the major adverse events after left ventricular assist device implantation. Risk of stroke is the highest immediately after left ventricular assist device implantation and then increases again in chronic periods. There is no study that has analyzed risk factors for stroke in acute phase. We investigated the risk factors for stroke in the acute phase after left ventricular assist device implantation in the present study. METHODS: Between October 2005 and December 2016, 158 consecutive patients (mean age, 43 ± 14 years; 34% were women) underwent continuous-flow left ventricular assist device (50 HeartMate II [Abbott Medical, Abbott Park, Ill], 38 DuraHeart [Terumo Heart, Ann Arbor, Mich], 33 Jarvik2000 [Jarvik Heart, New York, NY], 23 EVAHEART [Sun Medical, Moriyama City, Japan], 14 HeartWare [Framingham, Mass]) implantation in our institution. We analyzed the risk factors for a symptomatic stroke within 90 days after left ventricular assist device implantation. RESULTS: Stroke occurred in 28 patients in the acute phase after left ventricular assist device implantation. Multivariate analysis revealed that low cardiac output (odds ratio, 0.25; 0.07-0.92; P = .024) during postoperative 12 to 24 hours was the only independent risk factor for stroke in the acute phase. Patients with stroke in the acute phase had higher serum lactate dehydrogenase levels at any point until postoperative 14 days. Patients with the HeartMate II device particularly showed a statistically significant negative relationship between cardiac output during postoperative 12 to 24 hours and serum lactate dehydrogenase levels at postoperative 14 days (r = -0.313, P = .03). CONCLUSIONS: Our study demonstrated that patients with perioperative lower cardiac output and higher lactate dehydrogenase level developed stroke in the acute phase after left ventricular assist device implantation. These results suggested that maintenance of sufficient left ventricular assist device flow is important in prevention of stroke, which may be related to subclinical pump thrombosis.

Reoperation for a giant arch anastomotic pseudoaneurysm eleven years after total arch replacement with island reconstruction.

BACKGROUND: The long-term effects of some surgical treatment procedures of arch replacement for aortic dissection or aortic aneurysm are unknown. CASE PRESENTATION: The present study reports the case of a 68-year-old man admitted to our hospital for aortic arch anastomotic pseudoaneurysm with concomitant aortic root enlargement and coronary artery stenosis. Eleven years ago, at the age of 56 years, he underwent total arch replacement with island reconstruction for chronic aortic dissection. We performed a second total arch replacement, aortic root replacement, and coronary artery bypass, using a cardiopulmonary bypass with cannulation through the right subclavian artery, femoral artery, and femoral vein prior to re-sternotomy. We also used selective cerebral perfusion. Postoperatively, the patient temporarily required reintubation; however, he was discharged in good condition on the fiftieth postoperative day. CONCLUSIONS: This case suggests that island reconstruction has the potential to cause arch anastomotic pseudoaneurysms, particularly after a long postoperative period.

Relationship Between Bacteremia and Hemorrhagic Stroke in Patients With Continuous-Flow Left Ventricular Assist Device.

BACKGROUND: Blood stream infection is thought to increase the risk of hemorrhagic stroke, a major adverse event with devastating outcome, in patients with continuous-flow left ventricular assist devices (LVADs). We analyzed the risk factors of hemorrhagic stroke in LVAD patients, as well as the time relationship between systemic bacteremia and hemorrhagic stroke.Methods and Results:We evaluated the incidence of systemic bacteremia and stroke in 164 patients who underwent continuous-flow LVAD implantation between 2005 and 2016. At 1 and 2 years after implantation, the incidence of bacteremia was 29% and 36%, and the incidence of hemorrhagic stroke was 22% and 22% in patients without bacteremia, and 32% and 44% in those with bacteremia, respectively (P=0.035). This higher prevalence of hemorrhagic stroke in patients with bacteremia was notable particularly in the chronic phase (>90 days after implantation). Multivariate analysis revealed that bacteremia was an independent risk factor of hemorrhagic stroke in the chronic phase [hazard ratio, 2.36 (1.02-5.62); P=0.044]. The hazard rate was the highest immediately after the onset of bacteremia, and the risk steadily declined by 90 days after the last episode of bacteremia and flattened thereafter. CONCLUSIONS: Bacteremia was an independent risk factor of hemorrhagic stroke in patients in the chronic phase, with the highest risk seen in the early phase following an episode of bacteremia.

Midventricular Obstruction Caused by Abnormal Intra-Left Ventricular Septum and Papillary Muscles.

Abnormal papillary muscle is a rare cause of midventricular obstruction. In this case report, hypertrophied abnormal papillary muscles and abnormal tissue growth from the septal wall formed an intra-left ventricular septum with a small hole and resulted in severe midventricular obstruction. Radical resection of both papillary muscles and the intra-left ventricular septum was performed along with mitral valve replacement to relieve the obstruction.

Libman-Sacks Endocarditis Due to Systemic Lupus Erythematosus Activation After Mitral Valve Plasty.

Libman-Sacks endocarditis is a cardiac manifestation of systemic lupus erythematosus (SLE) and antiphospholipid syndrome. We report a case of mitral valve destruction due to Libman-Sacks endocarditis, which was caused by activation of SLE, despite prompt initiation of systemic steroid therapy. The prevention of SLE activation is critically important in valve surgery for patients with SLE. To the best of our knowledge, this is the first case of repaired mitral valve destruction due to activation of SLE, which was caused by valve surgery itself.

Non-occlusive mesenteric ischemia in a patient with left ventricular assist device implantation.

Non-occlusive mesenteric ischemia (NOMI) is a devastating complication after cardiac surgery. Once patients develop NOMI, intra-mesenteric infusion of vasodilators and/or emergent laparotomy is usually required, but the mortality is extraordinarily high even with intensive treatment. We present a case of salvage of a patient with NOMI complicated with severe right ventricular dysfunction after left ventricular assist device (LVAD) implantation using maximum treatment with emergent laparotomy and temporary right ventricular assist device implantation. To the best of our knowledge, this is the first successful salvage case of NOMI in a LVAD patient. We believe that hemodynamic optimization using maximum treatment is critically important to achieve salvage.

Short- and long-term results of radial artery and saphenous vein grafts in the right coronary system: a propensity-matched study.

PURPOSE: The selection of optimal grafts for the right coronary artery remains controversial. This study aims to evaluate the short- and long-term results of radial artery (RA) grafts and saphenous vein grafts (SVGs) to the right coronary artery. METHODS: We reviewed, retrospectively, isolated coronary artery bypass grafts, placed between 1997 and 2007, and compared the long-term results of patients who received RA (n = 110) grafts with those of patients who received SVGs (n = 264) using propensity-score matching for risk. The preoperative predictors of graft occlusion were investigated on a per case basis. RESULTS: Superior survival was noted in the unmatched RA group, but late outcomes after propensity-score matching yielded 91 patient pairs that were similar in the two groups. Graft failure was not correlated with mortality, but showed strong correlation with cardiac events in all patients. The predictors of graft occlusion in the RA group were mild proximal stenosis and low indexing glomerular filtration rates for body surface area, whereas those in the SVG were female gender and off-pump coronary artery bypass grafting. CONCLUSIONS: There were no significant differences in long-term outcomes between the RA and SVG groups. Predictors of graft occlusion differed between the groups. Notably, renal dysfunction impaired radial patency, emphasizing the importance of careful graft selection.

Paraplegia due to intramedullary hemorrhage after mitral valve repair.

We report the case of a patient who developed paraplegia after mitral valve repair and maze procedure. The first day after surgery, marked weakness of both lower extremities was noted. Neurologic examination showed almost complete loss of sensory and motor function below the level of the first thoracic vertebrae. Magnetic resonance imaging showed intramedullary hemorrhage ranging from the C7 to Th2 segments. Preoperative anticoagulation therapy and general heparinization during heart surgery may cause this rare complication.

Mitral valve regurgitation after atrial septal defect repair in adults.

BACKGROUND AND AIM OF THE STUDY: Mitral valve regurgitation (MR) is known to deteriorate following adult atrial septal defect (ASD) repair in the mid to long-term. The study aim was to identify the risk factors for this deterioration. METHODS: Between 1995 and 2011, a total of 93 consecutive patients (aged > or = 18 years) underwent ASD repair at the authors' institution. Patients who underwent concomitant procedures, other than tricuspid annuloplasty or maze procedure, were excluded; hence, 74 patients were enrolled in the study. MR was evaluated by transthoracic echocardiography shortly after surgery and subsequently on a regular basis in the outpatient clinic. Risk factors for the deterioration of MR were estimated using Cox proportional hazards regression. RESULTS: The mean patient age at surgery was 48.0 +/- 17.1 years, and 20 patients (27%) had atrial fibrillation (AF) preoperatively. The mean follow up was 6.9 +/- 5.5 years. The degree of MR was not unchanged or not improved in 54 patients (73.0%) (group 1), but was increased by one grade in 12 patients (16.2%) (group 2), and by two or more grades in eight patients (10.8%) (group 3). At surgery, all patients in group 3 were aged > 50 years. In group 3, on echocardiography, the average end-diastolic left ventricular dimension was increased from 41.8 mm to 51.8 mm (p = 0.027), and enlargement of the mitral annulus was noted in seven patients. Four of the group 3 patients required reoperation for MR after ASD repair. The Cox proportional hazards model revealed preoperative AF (p = 0.045, hazard ratio (HR): 11.68, 95% confidence interval (95% CI): 1.05-129.48) and Qp/Qs > or = 2.8 (p = 0.015, HR: 9.19, 95% CI :1.53-55.04) to be independent risk factors of new-onset or aggravated MR (by two or more grades) after ASD repair. CONCLUSION: An earlier repair of ASD would be preferable in terms of MR aggravated after ASD repair. For elderly patients with a preoperative high Qp/Qs and AF, mitral valve annuloplasty with ASD repair should considered.

Early outcomes and hemodynamics after implantation of the Trifecta aortic bioprosthesis.

OBJECTIVE: The Trifecta valve is a recent, newly designed high performance valve, with few studies on the clinical and hemodynamic data. The purpose of this study was to evaluate the early clinical and echocardiographic results of the Trifecta valve. METHODS: Between April 2012 and December 2012, 23 consecutive patients underwent aortic valve replacement with the Trifecta valve in our institution. Clinical and hemodynamic data were prospectively recorded and hemodynamic performance was assessed by transthoracic echocardiography. RESULTS: Nine patients were male and the overall mean age was 75 ± 9 years. Twenty patients suffered aortic stenosis, and 3 suffered aortic insufficiency. Prosthesis sizes implanted were: 19 mm (n = 4), 21 mm (n = 12), and 23 mm (n = 7). There were no 30-day deaths and no valve-related events during follow-up, except for 1 postoperative stroke. The mean postoperative transprosthetic pressure gradient was 10.0 ± 1.4, 9.6 ± 3.6, and 7.1 ± 3.6 mmHg, and the effective orifice area was 1.45 ± 0.13, 1.68 ± 0.16, and 1.90 ± 0.28 cm(2), for valve sizes 19, 21, and 23 mm, respectively. One patient had moderate prosthesis-patient mismatch. No moderate to severe aortic regurgitation was observed. The mean pressure gradient in aortic stenosis patients decreased significantly from 49.9 ± 20.7 to 8.9 ± 3.6 mmHg (p < 0.001). Left ventricular mass index in all patients decreased significantly from 142.0 ± 33.6 to 115.4 ± 26.4 g/m(2) (p < 0.001). CONCLUSIONS: The Trifecta aortic bioprosthesis provided satisfactory early outcomes and hemodynamic function.