ADAR1 Non-Editing Function in Macrophage Activation and Abdominal Aortic Aneurysm.

BACKGROUND: Macrophage activation plays a critical role in abdominal aortic aneurysm (AAA) development. However, molecular mechanisms controlling macrophage activation and vascular inflammation in AAA remain largely unknown. The objective of the study was to identify novel mechanisms underlying adenosine deaminase acting on RNA (ADAR1) function in macrophage activation and AAA formation. METHODS: Aortic transplantation was conducted to determine the importance of nonvascular ADAR1 in AAA development/dissection. Ang II (Angiotensin II) infusion of ApoE-/- mouse model combined with macrophage-specific knockout of ADAR1 was used to study ADAR1 macrophage-specific role in AAA formation/dissection. The relevance of macrophage ADAR1 to human AAA was examined using human aneurysm specimens. Moreover, a novel humanized AAA model was established to test the role of human macrophages in aneurysm formation in human arteries. RESULTS: Allograft transplantation of wild-type abdominal aortas to ADAR1+/- recipient mice significantly attenuated AAA formation, suggesting that nonvascular ADAR1 is essential for AAA development. ADAR1 deficiency in hematopoietic cells decreased the prevalence and severity of AAA while inhibited macrophage infiltration and aorta wall inflammation. ADAR1 deletion blocked the classic macrophage activation, diminished NF-κB (nuclear factor kappa B) signaling, and enhanced the expression of a number of anti-inflammatory microRNAs. Mechanistically, ADAR1 interacted with Drosha to promote its degradation, which attenuated Drosha-DGCR8 (DiGeorge syndrome critical region 8) interaction, and consequently inhibited pri- to pre-microRNA processing of microRNAs targeting IKKß, resulting in an increased IKKß (inhibitor of nuclear factor kappa-B) expression and enhanced NF-κB signaling. Significantly, ADAR1 was induced in macrophages and interacted with Drosha in human AAA lesions. Reconstitution of ADAR1-deficient, but not the wild type, human monocytes to immunodeficient mice blocked the aneurysm formation in transplanted human arteries. CONCLUSIONS: Macrophage ADAR1 promotes aneurysm formation in both mouse and human arteries through a novel mechanism, that is, Drosha protein degradation, which inhibits the processing of microRNAs targeting NF-kB signaling and thus elicits macrophage-mediated vascular inflammation in AAA.

Enhanced Reendothelialization and Thrombosis Prevention with a New Drug-Eluting Stent.

PURPOSE: The objective of the study is to test the efficacy of cyclopentenyl cytosine (CPEC)-coated stents on blocking artery stenosis, promoting reendothelialization, and reducing thrombosis. METHODS: Scanning electron microscopy was employed to observe the morphological characteristics of stents coated with a mixture of CPEC and poly(lactic-co-glycolic acid) (PLGA) copolymer. PLGA has been used in various Food and Drug Administration (FDA)-approved therapeutic devices. In vitro release of CPEC was tested to measure the dynamic drug elution. Comparison between CPEC- and everolimus-coated stents on neointimal formation and thrombosis formation was conducted after being implanted into the human internal mammary artery and grafted to the mouse aorta. RESULTS: Optimization in stent coating resulted in uniform and consistent coating with minimal variation. In vitro drug release tests demonstrated a gradual and progressive discharge of CPEC. CPEC- or everolimus-coated stents caused much less stenosis than bare-metal stents. However, CPEC stent-implanted arteries exhibited enhanced reendothelialization compared to everolimus stents. Mechanistically, CPEC-coated stents reduced the proliferation of vascular smooth muscle cells while simultaneously promoting reendothelialization. More significantly, unlike everolimus-coated stents, CPEC-coated stents showed a significant reduction in thrombosis formation even in the absence of ongoing anticoagulant treatment. CONCLUSIONS: The study establishes CPEC-coated stent as a promising new device for cardiovascular interventions. By enhancing reendothelialization and preventing thrombosis, CPEC offers advantages over conventional approaches, including the elimination of the need for anti-clogging drugs, which pave the way for improved therapeutic outcomes and management of atherosclerosis-related medical procedures.

Intraoperative Electroencephalogram-Guided Deep Hypothermia Plus Antegrade and/or Retrograde Cerebral Perfusion During Aortic Arch Surgery.

BACKGROUND: A number of intraoperative tools are used for brain monitoring in aortic arch surgery. We rely on intraoperative electroencephalogram (EEG) to guide deep hypothermic circulatory arrest. METHODS: Between July 2012 and June 2014, 157 patients underwent aortic arch surgery with deep hypothermic circulatory arrest performed by a single surgeon. Intraoperative EEG was used in 141 patients (89.8%). Our intraoperative strategy was to continue systemic cooling until no electrical waves were observed on the EEG. Once we confirmed electroencephalographic silence, we induced deep hypothermic circulatory arrest for aortic arch reconstruction. Retrograde cerebral perfusion was also used during hemiarch and distal arch replacements. Antegrade cerebral perfusion was added to total arch replacements. RESULTS: Patients' mean age was 59.1 ± 14.6 years. Hemiarch replacement was performed in 100 (63.7%), total arch replacement in 28 (17.8%), and distal arch replacement in 29 (18.5%). There were 30 urgent or emergency cases (19.1%). Circulatory arrest time was 28.8 ± 15.3 minutes. Thirty-day mortality occurred in four patients (2.5%). Postoperative stroke was diagnosed in five patients (3.2%). Major stroke led to 30-day mortality in two patients whose intraoperative EEG had shown abnormal recovery after systemic rewarming. One hundred thirty-five patients (95.7%) had normal recovery of EEG. Of these, three (2.2%) developed minor stroke consisting of minor hemiplegia. CONCLUSIONS: Intraoperative EEG is a reliable monitoring tool for safe circulatory arrest.

Late outcome of tricuspid annuloplasty using a flexible band/ring for functional tricuspid regurgitation.

BACKGROUND: We assessed late outcome after tricuspid annuloplasty (TAP) using a flexible band or ring for functional tricuspid regurgitation (FTR). METHODS AND RESULTS: We reviewed 220 consecutive patients (mean age, 65.4±11.4 years) who underwent TAP for FTR during mitral valve surgery between January 2000 and December 2010. Indications for TAP included the following: (1) TR grade greater than mild; (2) history of right heart failure; (3) atrial fibrillation; and (4) systolic pulmonary artery pressure (SPAP) ≥50 mmHg. The mean follow-up period was 4.4±2.6 years. Overall hospital mortality was 5.5% (12/220). The 5- and 10-year survival rates were 90.2±2.1% and 82.4±5.6%, respectively. Freedom from recurrent TR at 8 years was 78.0±6.6%. Twenty patients had a greater than mild TR grade at final follow-up. Elevated SPAP was a predictor of recurrent TR (hazard ratio, 1.091; P=0.0003), which was associated with advanced age, atrial fibrillation, rheumatic etiology and preoperative TR grade. There was a significant difference in freedom from valve-related events between residual TR greater than mild and less than moderate (log-rank test, P=0.0464). Factors affecting residual TR were preoperative TR grade (OR, 7.368; P=0.0267) and mitral valve replacement (OR, 4.369; P=0.0402). CONCLUSIONS: Late outcome of TAP in the present series was acceptable. Late outcome can be improved by performing TAP before deterioration of TR.

Efficacy of Stentless Aortic Bioprosthesis Implantation for Aortic Stenosis with Small Aortic Annulus.

BACKGROUND: In patients with small aortic annulus, sufficient size of stented aortic bioprosthesis cannot be implanted without additional procedures. In such cases, we use stentless aortic bioprosthesis to obtain sufficient effective orifice area. In this study, we investigated long-term impact of stentless aortic bioprosthesis on clinical outcomes, compared with stented aortic bioprosthesis. MATERIALS AND METHODS: We retrospectively investigated 140 patients who underwent aortic valve replacement (AVR) with porcine bioprosthesis for severe aortic stenosis between 1999 and 2010. Patients who had moderate or more aortic regurgitation and who underwent concomitant mitral procedures were excluded. A total of 69 patients (49%) were implanted stentless bioprosthesis (Freestyle group; Medtronic Inc, Minneapolis, Minnesota, United States) and 71 patients (51%) were implanted stented bioprosthesis (Mosaic group; Medtronic Inc). Follow-up was complete in 97.9% patients. Median follow-up period was 4.2 years. RESULTS: Patients in Freestyle group had smaller body surface area, smaller aortic annulus diameter, smaller aortic valve area, larger mean pressure gradient, higher peak velocity across aortic valve, larger left ventricular mass index (LVMI), and lower left ventricular ejection fraction (LVEF). Mean size of implanted prosthesis was larger in Freestyle group. In-hospital mortality was 1.4% in Freestyle group and 2.8% in Mosaic group (p = 0.980). Five-year survival rate was not different between two groups (5-year survival rate was 87.5 ± 4.7% in Freestyle group and 84.1 ± 7.5% in Mosaic group; log rank, p = 0.619). Late New York Heart Association functional class was lower in Freestyle group. Late LVMI and LVEF became similar between two groups. CONCLUSION: Stentless aortic bioprosthesis is superior in left ventricular remodeling after AVR for aortic stenosis and is especially effective for small aortic annulus.

Long-term outcomes after mitral valve repair for degenerative mitral regurgitation with persistent atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) adversely affects surgical outcomes of mitral valve surgery. However, the long-term impact of Maze procedure has not been clear yet. PATIENTS AND METHODS: We retrospectively investigated 159 patients who underwent mitral valve repair for degenerative mitral regurgitation with persistent AF between 1991 and 2010. The mean age of patients was 63.1 ± 10.5 years. After we started performing Maze procedure in 2002, 65 patients underwent concomitant Maze procedure. The median follow-up time was 7.5 years. RESULTS: There was one operative death (0.63%). The overall survival rate was 91.0 ± 2.6% at 5 years and 79.1 ± 4.7% at 10 years. Survival was significantly better in patients who underwent Maze procedure than those who did not. The rate of freedom from AF in patients who underwent Maze procedure was 86.4 ± 4.5% at 1 year and 81.1 ± 5.6% at 5 years. The freedom rate from stroke was higher in patients who underwent Maze procedure than those who did not. Patients with postoperative AF had larger left ventricular systolic and diastolic diameters at follow-up and higher New York Heart Association functional class than patients without postoperative AF (1.4 ± 0.5 vs. 1.1 ± 0.3, p < 0.001). CONCLUSION: Maze procedure can have a positive effect on long-term survival, freedom from stroke, and cardiac function.

Technical modifications in the repair of acute ischemic posterior ventricular septal defect without ventriculotomy.

OBJECTIVE: Transventricular repair for acute ischemic posterior ventricular septal defect is challenging and is associated with high operative morbidity and mortality. We have adopted the alternative technique of transatrial repair and recently have added technical modifications that result in less residual or recurrent septal shunt. This study reports those modifications and the related outcomes. METHODS: Retrospective review of 10 patients with acute ischemic posterior ventricular septal defect operated from November 2006 through March 2013. The septal defect was repaired through the right atrium with a prosthetic patch. Interlocking sutures and an additional continuous suture line buttress around the perimeter of the patch were added to the repair in four (40%) patients. RESULTS: Killip class IV heart failure was present in nine (90%) of the patients, and all received preoperative intra-aortic balloon pump therapy. No patient who received the recent technical modifications experienced a residual or recurrent shunt. However, three (50%) patients who did not undergo this modification developed either a residual septal shunt (n = 1), an early recurrent septal shunt (n = 1), or a ventricular rupture (n = 1). There was no 30-day or in-hospital mortality after surgery, but a single patient died two years after operation due to congestive heart failure. The remaining patients are alive after surgery at a median of 2.0 years. CONCLUSIONS: The transatrial repair of an acute ischemic posterior ventricular septal defect is a safe technique. The addition of interlocking pledgetted sutures and a patch suture line buttress decreases the incidence of residual and recurrent septal shunt.

Persistent tricuspid regurgitation after tricuspid annuloplasty during redo valve surgery affects late survival and valve-related events.

BACKGROUND: Long-term survival and incidence of late tricuspid regurgitation (TR) were studied in patients who underwent tricuspid annuloplasty (TAP) during redo valve surgery. METHODS AND RESULTS: We retrospectively analyzed 125 patients (mean age, 64.5±10.4 years) who underwent TAP using suture (n=54, group S) or ring (n=71, group R) implantation during redo surgery in a 20-year period. There was a significant difference in prevalence of preoperative atrial fibrillation (P=0.0199). More group S patients were in New York Heart Association functional class III or IV than group R patients (P=0.0066). Mean follow-up was 6.6±5.3 years. Mortality rate for group S was 9.3%, and for group R, 7.0% (P=0.6508). Survival at 5 and 10 years was 72.2±6.6% vs. 88.1±4.0%, and 66.4±7.3% vs. 61.0±7.2%, respectively (log-rank, P=0.7235). Less than moderate TR (hazard ratio [HR], 0.113; P=0.0198) before discharge was a predictor of late survival. There was no statistically significant difference in freedom from valve-related events (log-rank, P=0.5196). A predictor of freedom from valve-related events was less than moderate TR before discharge (HR 0.428; P=0.0100). It was also a positive predictor of freedom from late TR more than mild (HR 0.070; P<0.0001). CONCLUSIONS: Less than moderate TR before discharge after TAP during redo valve surgery was an independent risk factor for better long-term outcome.

Redo valvular surgery in elderly patients aged > 75 years.

BACKGROUND AND AIM OF THE STUDY: Very few data exist regarding the clinical outcome of redo valvular surgery in patients aged > 75 years. METHODS: A retrospective analysis was conducted of 42 consecutive patients (mean age 78.3 years) who had undergone redo valvular surgery between January 1991 and December 2010, and who had been followed up for a mean of 2.5 years. Factors associated with early outcomes were analyzed using logistic regression analysis, while predictors of late death and valve-related events were identified using Cox regression analysis. RESULTS: The overall hospital mortality rate of redo procedures was 17%. Multivariate logistic regression analysis showed that prolonged ventilator support (OR 1.007; 95% CI: 1.000-1.014; p < 0.0464) was an independent risk factor for hospital mortality. Overall survival rates at one and three years were 78.3 +/- 6.8% and 67.1 +/- 8.6%, respectively. Multivariate Cox regression analysis of survival revealed that age (HR 1.399; 95% CI: 1.044-1.875; p < 0.0238) and prolonged ventilator support (HR 1.004; 95% CI: 1.001-1.006; p < 0.0051) were negative predictors of mid-term survival. Rates of freedom for valve-related events at one and three years were 77.4 +/- 7.5% and 60.2 +/- 9.6%, respectively. An absence of peripheral artery disease protected against valve-related events (HR 0.045; 95% CI: 0.004-0.44; p < 0.0080). CONCLUSION: Early and late outcomes for elderly patients who had undergone redo valvular surgery were relatively poor and satisfactory, respectively. Hence, an optimal referral for redo surgery is important to achieve better outcomes.

Does the number of redo mitral valve replacements for structural valve deterioration affect early and late outcomes?: experience from 114 reoperative cases.

BACKGROUND AND AIM OF THE STUDY: Whether the number of reoperative mitral valve replacements (MVRs) for structural valve deterioration (SVD) affects early or late survival is unclear. Hence, the aim of the present study was to investigate this issue. METHODS: A total of 114 consecutive patients (84 females, 30 males; mean age 63.4 +/- 11.9 years) who underwent 141 redo MVRs for SVD during a 20-year period was retrospectively analyzed. Of these patients, 87 (76.3%) had undergone first-time reoperations (87 redos; group A), while the remaining 27 (23.7%) had undergone two or more reoperations (54 redos; group B). The mean follow up period was 8.5 +/- 6.8 years, and the follow up rate was 96.2%. RESULTS: NYHA functional class III or IV was noted in 34 patients (39.1%) of group A, and in 17 patients (63.0%) of group B (p = 0.0292). The EuroSCORE and logistic EuroSCORE in group B were significantly higher than those in group A. The hospital mortality rate was 4.6% in group A and 11.1% in group B (p = 0.1430). Logistic regression analysis revealed risk factors for hospital mortality to be the number of reoperations (OR 4.399; p = 0.0467) and NYHA class III or IV (OR 9.090; p = 0.0483). There were no significant differences in five-, 10- or 15-year survival rates between groups A and B (log-rank test, p = 0.3369). A Cox regression analysis showed advanced age to be the only predictor of late mortality (HR = 1.098; p = 0.0013). CONCLUSION: Irrespective of whether a patient has undergone two or more reoperative MVRs, a better long-term survival can be expected before progression of the patient's NYHA functional class.

Mitral valve repair for severe organic mitral regurgitation in the elderly.

BACKGROUND AND AIM OF THE STUDY: Although mitral valve repair has become the standard surgical procedure for mitral regurgitation (MR), the procedure does not necessarily apply to elderly patients aged > 75 years because of high morbidity and mortality. METHODS: A total of 104 patients aged > 75 years who underwent mitral valve repair between January 1991 and December 2011 was reviewed retrospectively. The mean age was 78 years, and the mean follow up was 3.7 years. Possible risk factors for hospital death and morbidity were identified, and valve-related events during the follow up period were analyzed. RESULTS: The overall hospital mortality rate was 4.8% (5/104). Multivariate logistic regression analysis identified serum creatinine level > 2.0 mg/dl as the only independent predictor of hospital mortality. A total of 33 patients had postoperative complications. Infective endocarditis was the only independent predictor of hospital morbidity. Actual survival at five years was 85.6 +/- 4.1%. By Cox regression analysis, age (HR 1.195; p <0.012) proved to be a negative predictor of late survival, whereas the absence of chronic obstructive pulmonary disease (HR 0.129; p <0.014) was a positive predictor. Rates of freedom from thromboembolic events and bleeding at five years were 87.9 +/- 4.2% and 97.9 +/- 1.5%, respectively. Rates of freedom from moderate-to-severe MR and reoperation at five years were 80.3 +/- 6.5% and 97.5 +/- 2.5%, respectively. CONCLUSION: Late survival and freedom from valve-related events were favorable, in addition to hospital outcome, in patients aged > 75 years. Mitral valve repair is an acceptable surgical procedure in terms of hospital mortality/morbidity and freedom from valve-related events.

Reoperation for pseudoaneurysm of the thoracic aorta after cardiovascular surgery.

PURPOSE: Pseudoaneurysms of the thoracic aorta after cardiovascular surgery are rare, but life-threatening complications. We herein describe the clinical outcomes of pseudoaneurysms of the thoracic aorta arising after cardiovascular surgery. METHODS: We retrospectively reviewed 14 patients (mean age 64 years) who underwent reoperation for a pseudoaneurysm of the thoracic aorta between January 1997 and December 2010. RESULTS: Pseudoaneurysms of the thoracic aorta were detected incidentally during routine follow-up in 11 asymptomatic patients, whereas symptoms or signs indicating an aortic pseudoaneurysm were present in three patients. The mean intervals between repeat and previous cardiovascular surgeries and the follow-up were 167 and 62 months, respectively. The aortic pseudoaneurysms were located in the proximal and distal suture lines in six patients, and at aortotomy sites in four. These locations accounted for about 70 % of all aortic pseudoaneurysms. None of the patients died in the hospital. Postoperative complications, such as a need for permanent pacemaker implantation or groin-related issues, occurred in five patients. However, no major postoperative complications, aorta-related events or a need for reoperation developed during the follow-up period. CONCLUSIONS: Regular follow-up, including imaging modalities and physical examinations, is mandatory to detect aortic pseudoaneurysms after cardiovascular surgery.

Pay attention to valvular disease in the presence of atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common skin condition in which Staphylococcus (S.) aureus can cause native valve destruction in patients with infective endocarditis (IE). The aim of this study was to determine the early and late outcomes of IE and AD. METHODS AND RESULTS: The medical records of patients with IE and AD who presented between January 1997 and September 2010 were analyzed retrospectively. IE and AD patients were compared with those with IE without AD. The mean follow-up period was 5.5±3.4 years. The incidence of AD among IE patients was 6.7% and they were significantly younger than those without AD (28.4 years vs. 53.7 years; P<0.0001). Methicillin-sensitive S. aureus and Streptococcus species were more prevalent in IE with AD (P<0.0001) and without AD (P=0.0259), respectively. One developed postoperative mediastinitis caused by methicillin-resistant S. aureus despite preoperative skin care. None of the patients died in hospital or had IE recurrence. Freedom from recurrent IE or prosthetic valve endocarditis at 5 years was 100±0.0%. CONCLUSIONS: Patients with IE must be checked for AD and history of AD because AD patients have a high incidence of staphylococcal colonization in their skin lesion.

Fate of functional tricuspid regurgitation after mitral valve repair for degenerative mitral regurgitation.

BACKGROUND: The issue of whether functional tricuspid regurgitation (TR) should be repaired at the time of mitral valve surgery is controversial, and the long-term durability of tricuspid valve (TV) annuloplasty remains unknown. METHODS AND RESULTS: We retrospectively reviewed 654 patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2010. Preoperative TR was classed as mild, trivial or absent in 479 (73.2%) patients, moderate in 125 (19.1%) patients and severe in 50 (7.7%) patients. Concomitant TV annuloplasty was performed in 162 patients (24.8%). The mean follow up duration was 7.5±4.9 years. Postoperative transthoracic echocardiography was performed according to a fixed schedule. The long-term survival rate and freedom from re-admission for congestive heart failure were affected by the severity of TR. Although the durability of ring annuloplasty was excellent up to 10 years after surgery, the mean TR grade started to increase after 10 years. Sixteen out of 492 patients who did not undergo TV annuloplasty (3.2%) revealed progression to severe TR. Preoperative atrial fibrillation (odds ratio (OR), 4.85; 95% confidence interval (CI), 1.38-17.1; P=0.014) and preoperative TR grade (OR, 5.16; 95% CI, 1.78-14.9; P=0.003) were predictors for progression to severe TR. CONCLUSIONS: Aggressive treatment with concomitant TV annuloplasty should be advocated in cases with atrial fibrillation and more than moderate TR.

Mechanism of and risk factors for reoperation after mitral valve repair for degenerative mitral regurgitation.

BACKGROUND: We reviewed our 20-year experience of mitral valve (MV) repair for degenerative mitral regurgitation (MR) and analyzed the mechanisms and risk factors of reoperation. METHODS AND RESULTS: Six hundred and fifty-four patients who underwent MV repair for degenerative MR between 1991 and 2010 were retrospectively reviewed. The mean follow-up duration was 7.5 ± 4.9 years. Late echocardiography was obtained at a fixed schedule. Standard procedures for MV repair were resection and suture for posterior prolapse, artificial chordal reconstruction for anterior prolapse and a combination of them for prolapse of both. Ring annuloplasty was performed in most cases. We encountered 2 early and 23 late reoperations. Fifteen (60%) were valve-related failure, 9 (36%) were procedure-related failure and 1 was unknown. Valve-related failure was characterized with recurrence of MR due to new prolapse region and progression of mitral stenosis due to leaflet thickening. For them, reoperation was performed at 7.6 years and 14.3 years after the initial operation, respectively. Multivariate analysis identified preoperative left ventricular diastolic diameter and residual regurgitation at discharge as risk factors for reoperation. CONCLUSIONS: Valve-related failure occurred late due to slow progression of degenerative disease. Long-term follow-up after surgery is mandatory. Given that progression and severity of MR were identified as risk factors for reoperation, early surgical intervention is desirable for degenerative MR.

Tricuspid leaflet augmentation with an autologous pericardial patch for recurrent severe tricuspid regurgitation that occurred after suture annuloplasty.

We, herein, report the use of tricuspid leaflet augmentation with an autologous pericardial patch to treat a patient with severe tricuspid regurgitation (TR) that occurred after suture annuloplasty. The patient underwent mitral valve replacement for rheumatic mitral disease and tricuspid suture annuloplasty for moderate TR 23 years ago. She developed right-sided heart failure associated with severe TR. Leaflet augmentation with an autologous pericardial patch and ring annuloplasty were applied at redo surgery. Postoperative echocardiography showed trivial TR with significant improvement of the patient's symptoms. We have now performed this technique on three cases of severe recurrent TR that occurred after suture annuloplasty, and excellent early results were obtained in each case.

Clinical outcome of emergency surgery for complicated acute type B aortic dissection.

BACKGROUND: The aim of the present study was to review the clinical profile and outcome of emergency surgery for complicated acute type B aortic dissection. METHODS AND RESULTS: A total of 34 consecutive patients requiring surgical treatment for complicated acute type B aortic dissection between 2003 and 2010 were examined. The median age was 64.0 years (range, 19-82 years). Indication for emergency surgery was aortic rupture in 11 patients, rapid expansion of the dissecting aorta in 5, dissection involving a non-dissecting aneurysm in 6, and organ malperfusion in 12. All of 3 patients with open aortic rupture died during surgery. Operative mortality was 9.7% (central operation, 14.2%; peripheral operation, 7.1%; thoracic endovascular aneurysm repair, 0%). There were 2 aortic ruptures within 1 week after operation. Two patients suffered from persistent organ malperfusion after emergency surgical relief of ischemia and died. The 1- and 5-year survival rates were 74.1 ± 8.1% and 64.8 ± 11.2%. The actual rate of freedom from aortic events at 1- and 5- years was 83.0 ± 7.0% and 58.7 ± 11.4%. CONCLUSIONS: Emergency surgery for complicated acute type B dissection still has a high mortality rate for patients with open rupture and critical visceral ischemia. Medical treatment is best given immediately after admission, and adequate surgical treatment without delay is crucial.

[Long-term result of the maze procedure for atrial fibrillation].

Long-term result of the maze operation is unknown. Anticoagulation therapy is controversial even after success of the maze operation. Between 1997 and 2008, 213 patients underwent the maze procedure. Atrial fibrillation (Af) was chronic in 151 patients and paroxysmal in 62. Concomitant mitral valve procedure were performed in 72%. Early mortality was 1.9%. By dismissal electrocardiography 157 patients (74%) wes free from Af. At the last follow-up (mean 38 +/- 30 months), late Af recurrence had occurred in 16 patients. Af recurrence had occurred within 1-year in 15 patients. Risk factors for late Af recurrence was left atrial dimension of 50 mm or greater (P<0.001). There was no difference in 5-year freedom from Af between the Cox maze procedure versions. Anticoagulation for patients with large left atrium is mandatory for 1-year after surgery.

Minimally Invasive Bicuspid Aortic Valve Repair Using Geometric Ring Annuloplasty.

A 51-year-old man with congestive heart failure, Sievers type 1 bicuspid aortic valve, and severe aortic insufficiency had an upper mini-sternotomy. The annulus was sized to 27 mm, and the nonfused cusp to a 21-mm bicuspid ring. Using the geometric annuloplasty ring, two 180° subcommissural ring post sutures, 3 nonfused looping annular sutures, and 4 fused annular sutures were placed. Plication sutures raised noncoronary leaflet to a reference effective height of 10 mm, and fused leaflet cleft was closed linearly to the same effective height and length. Post-repair echocardiography showed good leaflet mobility, no residual leak, and a mean valve gradient of 10 mm Hg.