Angiotensin Receptor-Neprilysin Inhibitor Suppresses Renin-Angiotensin-Aldosterone System Activation After Cardiac Surgery Using Cardiopulmonary Bypass.

BACKGROUND: Sacubitril/valsartan, being both a neprilysin inhibitor and angiotensin receptor blocker, exhibits a renin-angiotensin-aldosterone system (RAAS) inhibitory effect. However, no study has investigated the administration of sacubitril/valsartan in patients early after surgery using cardiopulmonary bypass.Methods and Results: This was a prospective observational study of 63 patients who underwent open heart surgery and were treated with sacubitril/valsartan. No serious adverse events occurred. Among the 63 patients, sacubitril/valsartan was discontinued in 13 due to hypotension (n=10), renal dysfunction (n=2), and dizziness (n=1). Atrial natriuretic peptide concentrations increased significantly from Day 3 of treatment (P=0.0142 vs. Postoperative Day 1) and remained high thereafter. In contrast, plasma renin activity was significantly suppressed from Day 3 onwards (P=0.00206 vs. Postoperative Day 1). A decrease in creatinine concentrations and an increase in the estimated glomerular filtration rate were observed on Day 3; this improvement in renal function was not observed in the historical control group, in which patients did not receive sacubitril/valsartan. New postoperative atrial fibrillation was less frequent in the study group compared with the historical control (12.7% vs. 38.0%; P=0.0034). CONCLUSIONS: Sacubitril/valsartan administration was safe immediately after open heart surgery in patients without postoperative hypotension. It enhanced serum atrial natriuretic peptide concentrations and suppressed RAAS activation.

Impact assessment of mandatory safety device installation for gas stoves.

Numerous fire accidents have occurred in Japan owing to food overheating when cooking on gas stoves because users left the cooking area unattended. In response, authorities enacted a legal revision mandating temperature sensor installation on gas stove burners. Nevertheless, the actual effectiveness of this measure remains uncertain. Furthermore, prior studies have raised concerns about the efficacy of specific safety standards for consumer products owing to insufficient evidence of reduction in accidents. Consequently, this study seeks to assess the impact of the standards revision implemented in 2008, requiring the placement of safety devices on all gas stove burners. Through a comprehensive analysis, it was aimed to ascertain how these measures have precisely influenced safety outcomes in cooking-related incidents. The data in this study were subdivided to mitigate potential bias from user attributes during data collection. The analysis employed the difference-in-differences method, specifically utilizing one-burner gas stoves unaffected by the standards revision. The data used in this study include accidents associated with gas stoves, spanning the period 2007-2019. To estimate the likelihood of overheating accidents, a binomial distribution model that utilized the Markov chain Monte Carlo methods was applied. For gas stoves with two or more burners, which were affected by the standards revision, the estimated probability of overheating accidents decreased by approximately 80%. In contrast, no decreasing trend was observed for one-burner gas stoves. The analysis suggests that the mandatory installation of safety devices on gas stoves has indeed resulted in a significant reduction in overheating accidents.

Simulation to determine the approach of transcatheter aortic valve implantation in patients undergoing hemodialysis.

PURPOSE: The present study investigated potential access vessels in patients receiving hemodialysis who underwent surgical aortic valve replacement and determined which approaches were most suitable for performing transcatheter aortic valve implantation. METHODS: Consecutive patients undergoing hemodialysis with aortic valve stenosis who underwent surgical aortic valve replacement were included. Preoperative computed tomography data were analyzed to assess the vessel diameter and calcification. Simulations were conducted to determine the feasibility of inserting the 14-F eSheath of Sapien 3 via transfemoral, trans-cervical, trans-subclavian, and direct aorta approaches. RESULTS: A total of 72 patients were included in this study. The access route was characterized by severe calcification of the common iliac artery. The transfemoral approach was feasible in 77.8% of the cases, but the rate decreased to 33% when the calculations were based on the maximum sheath extension diameter. The trans-cervical, trans-subclavian, and direct aortic approaches were suitable for many patients. Lower extremity artery disease was identified as a risk factor for the unsuitability of the transfemoral approach. CONCLUSIONS: Common iliac artery calcification in patients undergoing hemodialysis restricts the use of the transfemoral approach. Therefore, some patients require alternative approaches.

How should cardiac xenotransplantation be initiated in Japan?

The world's first clinical cardiac xenotransplantation, using a genetically engineered pig heart with 10 gene modifications, prolonged the life of a 57-year-old man with no other life-saving options, by 60 days. It is foreseeable that xenotransplantation will be introduced in clinical practice in the United States. However, little clinical or regulatory progress has been made in the field of xenotransplantation in Japan in recent years. Japan seems to be heading toward a "device lag", and the over-importation of medical devices and technology in the medical field is becoming problematic. In this review, we discuss the concept of pig-heart xenotransplantation, including the pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental heart overgrowth, as well as genetic modification strategies in pigs to prevent or minimize these problems. Moreover, we summarize the necessity for and current status of xenotransplantation worldwide, and future prospects in Japan, with the aim of initiating xenotransplantation in Japan using genetically modified pigs without a global delay. It is imperative that this study prompts the initiation of preclinical xenotransplantation research using non-human primates and leads to clinical studies.

A protocol-based treatment for ruptured abdominal aortic aneurysm contributed to improving aorta-related mortality: a retrospective cohort study.

BACKGROUND: Recent guidelines state that improving the survival rate of patients with ruptured abdominal aortic aneurysm (rAAA) requires a protocol or algorithm for the emergency management of these patients. We aimed to investigate whether introducing a protocol treatment for rAAA improves clinical outcomes compared with the pre-protocol strategy. METHODS: At our institution, 92 patients treated for rAAA between June 2008 and August 2022 were retrospectively analyzed. In 2014, the protocol-based treatment was introduced comprising a transfer algorithm to shorten the time to proximal control, use of an endovascular occlusion balloon, strict indications for endovascular aortic aneurysm repair (EVAR) or open surgical repair, and perioperative care, including for abdominal compartment syndrome (ACS). Clinical outcomes were compared between the protocol and pre-protocol group, including operative status, all-cause mortality, and rAAA-related death at 30-day, in-hospital, and 1-year postoperative follow-ups. RESULTS: Overall, 52 and 40 patients received the protocol-based and pre-protocol treatments, respectively. EVAR was more frequently performed in the protocol group. The rate of achieving time to proximal control was significantly faster, and the transfusion volume was lower in the protocol group. ACS occurred more frequently in the protocol group with a higher EVAR. No difference was found in all-cause mortality between the two groups. The protocol group exhibited fewer rAAA-related deaths than the pre-protocol group during the following time points: 30 days (9.6% vs. 22.5%), during the hospital stay (11.5% vs. 30.0%), and 1 year (14.5% vs. 31.5%). CONCLUSIONS: The protocol-based treatment improved the survival rate of patients with rAAA.

A safe and sustainable bacterial cellulose nanofiber separator for lithium rechargeable batteries.

Bacterial cellulose nanofiber (BCNF) with high thermal stability produced by an ecofriendly process has emerged as a promising solution to realize safe and sustainable materials in the large-scale battery. However, an understanding of the actual thermal behavior of the BCNF in the full-cell battery has been lacking, and the yield is still limited for commercialization. Here, we report the entire process of BCNF production and battery manufacture. We systematically constructed a strain with the highest yield (31.5%) by increasing metabolic flux and improved safety by introducing a Lewis base to overcome thermochemical degradation in the battery. This report will open ways of exploiting the BCNF as a "single-layer" separator, a good alternative to the existing chemical-derived one, and thus can greatly contribute to solving the environmental and safety issues.

Severe Coagulopathy in a Patient With Short Bowel Syndrome.

BACKGROUND: Short bowel syndrome (SBS) refers to a malabsorptive state caused by extensive resection of the intestinal tract that leads to chronic diarrhea, electrolyte disturbances, and malnutrition. Although relatively uncommon, patients with SBS can present to the emergency department with more serious complications that are potentially life-threatening. Among these complications, coagulopathy secondary to SBS is an underrecognized condition. CASE REPORT: We present a case of severe coagulopathy secondary to vitamin K deficiency in SBS. The patient presented with unexplained coagulopathy and spontaneous bleeding in multiple organs. With a review of surgical history and detailed clinical evaluation, SBS complicated with vitamin K deficiency was diagnosed, and the patient was treated successfully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When a patient with a history of repeated intestinal surgery presents with diarrhea, malnutrition, or electrolyte abnormalities, emergency physicians should suspect SBS. Among complications of SBS, vitamin K deficiency is a rare but serious cause of unexplained coagulopathy presenting to the emergency department. Understanding the pathophysiology of SBS facilitates early identification of complications and improves patient outcomes.

Recovery From Exhaustion of the Frank-Starling Mechanism by Mechanical Unloading With a Continuous-Flow Ventricular Assist Device.

BACKGROUND: We describe our original left ventricular assist device (LVAD) speed ramp and volume loading test designed to evaluate native heart function under continuous-flow LVAD support.Methods and Results:LVAD speed was decreased in 4 stages from the patient's optimal speed to the minimum setting for each device. Under minimal LVAD support, patients were subjected to saline loading (body weight [kg]×10 mL in 15 min). Echocardiographic and hemodynamic data were obtained at each stage of the LVAD speed ramp and every 3 min during saline loading. Patients were divided into Recovery (with successful LVAD removal; n=8) and Non-recovery (others; n=31) groups. During testing, increased pulmonary capillary wedge pressure caused by volume loading was milder in the Recovery than Non-recovery group (repeated measures analysis of variance; group effect, P=0.0069; time effect, P<0.0001; interaction effect, P=0.0173). Increased cardiac output from volume loading was significantly higher in the Recovery than Non-recovery group (group effect, P=0.0124; time effect, P<0.0001; interaction effect, P=0.0091). Therefore, the Frank-Starling curve of the Recovery group was located upward and to the left of that of the Non-recovery group. CONCLUSIONS: The LVAD speed ramp and volume loading test facilitates the precise evaluation of native heart function during continuous-flow LVAD support.

Jarvik 2000 with postauricular cable as destination therapy: first clinical case in Japan.

Currently in Japan, a left ventricular assist device powered by an abdominal driveline is the only type of left ventricular assist device available. The driveline is vulnerable to infection secondary to inappropriate fixation and the traditional Japanese custom of bathing is prohibited in patients with an abdominal driveline. The Jarvik 2000 with postauricular cable is a left ventricular assist device in which the driveline exits the body behind the ear (postauricular) instead of exiting through an abdominal site. This case report is the first to describe the implantation of Jarvik 2000 with postauricular cable as destination therapy in a Japanese patient. This device enables patients to take a bath and may reduce the incidence of driveline infection.

Rescuing Patients With Severe Biventricular Failure in the Era of Continuous-Flow Left Ventricular Assist Device.

BACKGROUND: We evaluated clinical outcomes of left ventricular assist device (LVAD) support in patients with or without severe right heart failure, in order to determine what kind of organ allocation system could help severe biventricular failure patients to be safely bridged to heart transplantation (HTx), even in Japan where the waiting time for HTx is extremely long. Methods and Results: One hundred and seventy consecutive patients who were implanted with continuous-flow LVAD at the present institution were included in this study. The patients were divided into 2 groups: 158 patients with isolated LVAD (group-LVF) and 12 patients who required long-term mechanical or inotropic right heart support (group-BVF). Post-LVAD survival in group-BVF was significantly worse than in group-LVF (P<0.0001). Given that many patients in group-BVF died between 1 and 2 years after LVAD implantation, Kaplan-Meier survival curve simulation was carried out under the condition that all the patients in group-BVF who died on LVAD support >1 year after LVAD implantation had received HTx at 365 days after LVAD implantation and survived thereafter. In this simulation, no significant difference in survival was seen between the groups (P=0.2424). CONCLUSIONS: A new allocation system that allows severe right heart failure patients to receive HTx at around 1 year would enable rescue of the patients with severe right heart failure.

Effect of Continuous-Flow Mechanical Circulatory Support on Microvasculature Remodeling in the Failing Heart.

Left ventricle (LV) unloading caused by a left ventricular assist device (LVAD) has been shown to enhance reverse LV remodeling in end-stage cardiomyopathy. Several reports consistently suggest that a pulsatile-flow LVAD has more profound effects compared to continuous-flow LVAD, though the responsible mechanisms are not fully understood. We hypothesized that arterial pulsatility, being affected by the type of LVAD, may affect microvasculature and functional/pathological LV remodeling in end-stage cardiomyopathy. The study included 18 patients with chronic heart failure who underwent LVAD implantation. Eight patients were implanted with pulsatile-flow LVAD, and 10 patients were implanted with continuous-flow LVAD. The results of serial echocardiograms and histopathological assessment of transmural LV tissues, which were collected during the implantation and removal of LVADs, were compared between the groups. The results of echocardiography showed that LV systolic dimension and LV ejection fraction improved greatly in the pulsatile-flow LVAD group compared to the continuous-flow LVAD group. Histological analysis showed that in both groups, increased microvasculature density and decreased cardiomyocyte size during LVAD support had no significant difference. In contrast, only the patients with continuous-flow LVADs had presented with significant increase in α-smooth muscle actin (α-SMA)-positive layer thickness and the number of proliferating cell nuclear antigen (PCNA)-positive cells of myocardial arterioles. We concluded that the use of long-term continuous-flow LVAD support, having less pulsatility, had induced more thickening to the medial layer of myocardial arterioles compared to the use of pulsatile-flow LVADs. Our findings suggest that the pathological impairment of myocardial microvascular structure during continuous-flow LVAD support may be a novel mechanism which accounts for the difference in LV remodeling depending on the type of LVAD.

Therapeutic hypothermia after global cerebral ischemia due to left ventricular assist device malfunction.

Herein we report the case of a patient who suffered from global cerebral ischemia due to pump stoppage of Jarvik2000 Left ventricular assist device (LVAD) for unknown reason and fatal ventricular arrhythmia at home. Cardiopulmonary resuscitation was started by paramedics 6-7 min after the patient fell down. The patient was transferred to our hospital after the restoration of the LVAD function by exchanging external cables. Mild therapeutic hypothermia was induced and body temperature was kept at 33 °C for 24 h. After rewarming, the patient recovered his consciousness without any neurological deficit.

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.

Cardiac Function and Type of Mitral Valve Surgery Affect Postoperative Blood Flow Pattern in the Left Ventricle.

BACKGROUND: To determine the impact of cardiac function and type of mitral valve (MV) surgery on blood flow and energy loss in the left ventricle (LV). Methods and Results: This study enrolled patients with ejection fraction (EF) <35% or >50%; both groups had native (n=27 and n=16), repaired (n=19 and n=33), or prosthetic MVs (n=18 and n=19). They were examined by echocardiography-based vector flow mapping to assess the LV blood flow pattern and energy loss per heartbeat. Among patients with preserved EF, those with native MVs displayed a clockwise vortex and relatively low energy loss. In contrast, MV replacement induced a counterclockwise vortex producing higher energy loss than MV repair, which induced a normal clockwise vortex. This indicated the need for MV repair to minimize LV energy loss after surgery. Among the patients with reduced EF, those with native MVs showed a blood flow pattern similar to those with preserved EF and native MVs; furthermore, those with repaired MVs and half of the patients with prosthetic MVs displayed a clockwise vortex, resulting in no difference in energy loss between the 2 types of MV surgery. CONCLUSIONS: Cardiac function and the type of MV surgery are factors affecting the postoperative LV blood flow pattern. MV replacement resulted in abnormal blood flow with normal cardiac function, whereas advanced cardiomyopathy modified the blood flow pattern post-MV replacement.

Definitive Determinant of Late Significant Tricuspid Regurgitation After Aortic Valve Replacement.

BACKGROUND: Uncertainties remain regarding the course of existing tricuspid regurgitation (TR) after aortic valve replacement (AVR), and its long-term impact on outcome. We investigated changes in existing TR after isolated AVR for severe aortic stenosis (AS), the impact of preoperative TR on long-term outcome, and predictors of late significant TR.Methods and Results:After excluding mild mitral regurgitation and severe TR, 226 consecutive patients undergoing isolated AVR for severe AS between 2002 and 2015 were reviewed. Patients were classified into a non-TR (none/trivial preoperative TR, n=159) and a TR group (mild/moderate preoperative TR, n=67). During follow-up (median, 4.3 years), late significant TR was more prevalent in the TR group (n=20; 35.0%) than in the non-TR group (n=13; 9.6%; HR, 10.0; 95% CI: 4.44-24.7; P<0.001). The TR group developed more right heart failure (n=3; 5% vs. no patients in the non-TR group, P=0.007), and had a decreased estimated glomerular filtration rate (relative to baseline) until 5 years postoperatively. The tricuspid annulus diameter index was an independent predictor of late significant TR development. CONCLUSIONS: Preoperative mild or moderate TR is aggravated after isolated AVR, resulting in a high incidence of renal dysfunction and right heart failure. Concomitant tricuspid valve intervention should be considered in patients undergoing AVR for severe AS with mild or moderate TR accompanied by dilated tricuspid annulus.

Factors Related to the Severity of Early Postoperative Infection After Heart Transplantation in Patients Surviving Prolonged Mechanical Support Periods: Experience at a Single University.

OBJECTIVE: The authors examined the effect of prolonged support with continuous-flow ventricular assist devices (CF-VADs) and other related factors on the severity of infections within 30 days of heart transplantation (HTx). DESIGN: A retrospective analysis of consecutive HTx procedures. SETTING: University hospital, between 2010 and 2016. PARTICIPANTS: A cohort of 53 heart transplantation recipients (median age, 38.5 yr; interquartile range [IQR], 30.3-49.2 yr; women, 34%). INTERVENTIONS: Forty-nine patients required CF-VAD support (median duration, 946 d; IQR, 600-1,132 d). MEASUREMENTS AND MAIN RESULTS: Severity of postoperative infections was categorized as follows: no infection, minor infection (resolved within 14 days), major infection (resolved after >14 days), and severe infection (septic shock). Results were expressed as number (frequency) and median with IQR. Potential risk factors for increased infection severity were expressed as odds ratio (OR) with 95% confidence interval (CI). Postoperatively, no infection, minor infection, major infection, and severe infection occurred in 32 (60.4%), 8 (15.1%), 8 (15.1%), and 5 patients (9.4%), respectively. Active ventricular assist device (VAD)-specific infections at the time of HTx occurred in 37.7% of patients. Moderate-to-severe primary graft dysfunction occurred in 26.4% of the patients. Multivariable analysis indicated that risk factors for increased infection severity included active VAD-specific infection (OR 4.8; 95% CI 2.3-11.2) and moderate-to-severe primary graft dysfunction (OR 8.8; 95% CI 2.1-42.5) but not duration of CF-VAD support (OR 1.0; 95% CI 1.0-1.0). CONCLUSION: Active VAD-specific infection and poor graft function likely contribute to the severity of early postoperative infections after HTx.

Colonic fistula caused by remaining inflow cannula 14 years after left ventricular assist device explantation.

Intestinal complication associated with left ventricular assist device (LVAD) implantation is not rare, and sometimes results in serious condition of patients, if occurred. We report a rare case in which remaining foreign body after LVAD explantation resulted in colonic fistula 14 years after LVAD explantation.

Diagnosis, medical treatment, and stepwise mechanical circulatory support for fulminat myocarditis.

Fulminant myocarditis is one of the most challenging diseases. We sought to examine the outcomes of our multidisciplinary treatment strategy for fulminant myocarditis. A retrospective review of consecutive 30 patients with fulminant myocarditis was conducted. Of the 30 patients, 25 required mechanical circulatory support (MCS). Percutaneous extracorporeal membrane oxygenation (ECMO) was the first-line therapy to rescue the patients and inserted in 23 of them. The other 2 were implanted with temporary ventricular assist device (t-VAD) with extracorporeal centrifugal pump(s). Sixteen of the ECMO-supported patients were later transitioned to t-VAD. Of the 18 patients who underwent t-VAD support, heart function recovered and the VAD was explanted in 10. Four patients were bridged to long-term VAD and the other 4 died on t-VAD. Two patients were directly bridged to long-term VAD by ECMO. Heart function recovered only with ECMO in 4 patients and 1 died on ECMO. Overall survival rate was 83.3%. The duration of ECMO support significantly correlated with total bilirubin level, which was a significant risk factor for mortality. Pathologically, 7 patients (23.3%) had eosinophilic myocarditis and 1 (3.3%) had giant-cell myocarditis, and all the 8 patients underwent immunosuppressive therapy including steroids. Heart function recovered to normal level in 7 of them (87.5%). Timely conversion from the percutaneous ECMO to the temporary VAD before elevation of total bilirubin level is crucial for improving the clinical outcomes. Endomyocardial biopsy is needed to be done as soon as possible, because immunosuppressive therapy carries promising outcomes in certain etiologies.

The Adaptive Remodeling of the Anterior Mitral Leaflet and Chordae Tendineae Is Associated with Mitral Valve Function in Advanced Ischemic and Nonischemic Dilated Cardiomyopathy.

The degree or nature of functional mitral regurgitation (MR) is not necessarily correlated with the size or function of the left ventricle (LV). We hypothesized that the anatomical structure of the mitral valve (MV) complex might play a role in functional MR in ischemic or nonischemic dilated cardiomyopathy (DCM).The structure of the LV and MV complex in DCM patients (n = 29) was assessed using electrocardiogram-gated 320-slice computed tomography and was compared with that in healthy patients (n = 12). Twenty-five DCM patients with mild or low MR (DCM-lowMR) had markedly greater length, diameter, and sphericity index of the LV and a larger tenting area than the controls. The distance between the papillary muscle (PM) tip and the mitral annular plane was not different between DCM-lowMR and normal hearts despite the greater LV length observed in DCM-lowMR. Furthermore, DCM-lowMR had markedly longer chordae tendineae (DCM-lowMR: 24 [20-26] mm; controls: 14 [13-16] mm; P < 0.01) and larger anterior leaflets (DCM-lowMR: 30 [27-31] mm; controls: 22 [20-24] mm; P < 0.01), thus suggesting the adaptive remodeling of the MV complex. Four DCM patients with moderate-severe MR had unbalanced remodeling, such as excessive LV dilatation, short anterior mitral leaflets, and short chordae tendineae.The development of functional MR might be associated with the remodeling of LV and MV components, such as the PMs, chordae tendineae, or anterior MV leaflets. Detailed anatomical assessments of the LV and MV complex would contribute to the adequate staging of ischemic or nonischemic DCM.

Predictors and Clinical Impact of Functional Mitral Stenosis Induced by Restrictive Annuloplasty for Ischemic and Functional Mitral Regurgitation.

BACKGROUND: There are few reports of the determinants of "functional" mitral stenosis in terms of a residual mitral valve (MV) pressure gradient >5 mmHg following restrictive mitral annuloplasty (RMA) or the effect on long-term outcome in patients with functional mitral regurgitation (MR).Methods and Results:Serial cardiac catheterization and echocardiographic studies were performed in 55 patients with functional MR who underwent RMA using a 24/26-mm semi-rigid complete ring. The mean postoperative (1 month) catheter-measured MV gradient was 3.4±1.6 mmHg, which was independently associated with corresponding cardiac output [standardized partial regression coefficient (SPRC)=0.59] and indexed effective orifice area (SPRC=-0.25). Body surface area (BSA) had the greatest contribution to MV gradient (SPRC=0.38), followed by use of a 24-mm ring (SPRC=0.33) and hemodialysis (SPRC=0.26). Receiver-operating characteristic curve analysis demonstrated an optimal BSA cutoff value of 1.86 m2to predict post-MV stenosis (21% for <1.86 m2vs. 86% for ≥1.86 m2, P=0.002). During follow-up (75±32 months), freedom from adverse events did not differ between patients with (n=16) and without (n=39) an MV gradient ≥5 mmHg (log-rank P=0.24). CONCLUSIONS: Post-RMA MV gradient was determined not only by the degree of annular reduction but also by patients' hemodynamic factors (e.g., cardiac output). Implantation of a 24/26-mm annuloplasty ring for patients with BSA ≥1.86 m2indicated a high likelihood of post-MV stenosis. However, mild MV stenosis did not adversely affect late outcome after RMA.