Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis Complicated by Sigmoid Septum.

BACKGROUND: In patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS), a sigmoid septum, characterized by subaortic interventricular hypertrophy, often results in the need for new pacemaker implantation (PMI). In this study, we reviewed the feasibility and treatment efficacy of TAVR for AS in patients with a sigmoid septum. Methods and Results: Between 2011 and 2016, 48 patients (25.4%; mean age 84.9±5.4 years; 9 males) with a sigmoid septum and 141 (74.6%; mean age 82.9±5.5 years; 61 males) without underwent TAVR. Their operative outcomes, echocardiographic and electrocardiographic findings, and long-term outcomes were retrospectively compared. Second TAVR because of valve malposition was performed in 3 patients with a sigmoid septum (6.3%) and in 2 patients without a sigmoid septum (1.4%), with no significant difference between the 2 groups. Although there was no significant difference in valve hemodynamics between the 2 groups, sigmoid septum and deep implantation (implantation depth ≥10 mm) were independent predictors of new PMI following TAVR. CONCLUSIONS: Although a sigmoid septum did not preclude the feasibility, safety, or efficacy of TAVR for severe AS, its presence was associated with new PMI. Our approach to TAVR in patients with a sigmoid septum may contribute to clinical outcomes comparable to those of patients without this pathology.

Efficacy of regional saturation of oxygen monitor using near-infrared spectroscopy for lower limb ischemia during minimally invasive cardiac surgery.

Lower limb ischemia with an occlusive cannula is a potential complication of minimally invasive cardiac surgery (MICS). We evaluated intraoperative local oxygen supply-demand balance by monitoring regional saturation of oxygen (rSO2) using near-infrared spectroscopy (NIRS), and analyzed the correlation between cannula size and fluctuation range of rSO2. Fifty-four patients undergoing MICS surgery using femoral artery cannulation from April 2015 to August 2016 were enrolled. The rSO2 of both the cannulated and uncannulated lower limbs were measured using NIRS. The association between the decline of rSO2 from baseline (delta-rSO2) and the ratio of the cannula diameter to the femoral artery diameter (Cd/FAd) was analyzed. Of the 54 patients, 16 (30%) (Group 1) showed values over 0.65 for Cd/FAd, and the remaining 38 (70%) (Group 2) showed values under 0.65. No patient developed postoperative lower limb ischemia. No patient was treated with an ipsilateral distal perfusion cannula. There were significant differences between Group 1 and Group 2 in the decrease of rSO2 at the point of cannulation on the cannulated limb. In the lower limb on the cannulated side, delta-rSO2 showed a significant decrease in Group 1 compared to Group 2 (Group 1 vs Group 2: 19.9 vs 11.0%; p < 0.001). Delta-rSO2 was significantly correlated with body surface aera (BSA), but not with gender or age. Decreasing rSO2 correlates with the Cd/FAd index. Low BSA, Cd/Fad > 0.65 is considered as the risk factor for decline of rSO2 in cannulated limb in MICS.

Long-Term Outcomes of Suture vs. Ring Tricuspid Annuloplasty for Functional Tricuspid Regurgitation.

BACKGROUND: Whether there is a significant difference in the long-term surgical outcomes between suture annuloplasty and ring annuloplasty for the treatment of functional tricuspid regurgitation (TR) is still controversial. We compared the long-term outcomes of tricuspid annuloplasty (TAP) with and without an annuloplasty ring.Methods and Results:From January 1996 to December 2015, we consecutively enrolled 684 patients (mean age, 65.5 years; 60% women) undergoing TAP for functional TR: 312 underwent conventional suture annuloplasty (Group S) and 372 underwent ring annuloplasty (Group R). Baseline characteristics were comparable between the 2 groups, except for age and the prevalence of prior cardiac surgery. The mean follow-up period was 7.3 years (range, 0.3-20.3 years).There was no significant difference in overall survival, freedom from major adverse cardiac and cerebrovascular events, and freedom from recurrent moderate to severe TR between Groups S and R, although postoperative mean TR grade and sPAP were significantly lower in Group R. Multivariate analysis revealed that age, prior cardiac surgery, and preoperative severe TR were independent predictors of recurrent moderate or greater TR. CONCLUSIONS: There was no significant difference in the long-term surgical outcomes between ring and suture TAP, although postoperative mean TR grade was lower in the ring annuloplasty group.

Reducing Prosthesis-Patient Mismatch With Edwards Magna Prosthesis for Aortic Valve Replacement.

BACKGROUND: Prosthesis-patient mismatch (PPM) is associated with increased mid-term and long-term mortality rates after aortic valve replacement (AVR). This study aimed to evaluate the efficacy of the Carpentier-Edwards Perimount Magna and Magna Ease (CEPMs) aortic bioprostheses to reduce the incidence of PPM.Methods and Results:Altogether, 282 consecutive patients (113 women, mean age 69.9±9.9 years) underwent AVR with a CEPMs between 2008 and 2015. They were divided into 3 groups based on the risk of PPM as a result of their body surface area and aortic annular diameter (BSA/AnnD ratio): low-risk (LR) group: 0.64±0.05 m2/cm (n=94); medium-risk (MR) group: 0.73±0.02 m2/cm (n=94); high-risk (HR) group: 0.83±0.05 m2/cm (n=94). The 30-day mortality rate was 0.4%. The 5-year actuarial survival rates were 93.2%, 92.3%, and 94.8% for groups LR, MR, and HR, respectively. No explants as a result of structural valve deterioration occurred. No patients showed severe PPM, defined as a measured effective orifice area index (EOAI) <0.65 cm2/m2. Although there were significant (P<0.05) differences in EOAI (0.98±0.2, 0.90±0.21, and 0.88±0.1 cm2/m2among the LR, MR, and HR groups, respectively), the corresponding transvalvular mean pressure gradients (13.0±5.5, 12.3±4.0, 12.7±5.3 mmHg) and regression rates of the left ventricular mass (29.8%, 28.7%, 28.9%) were similar among groups. CONCLUSIONS: CEPMs provide low surgical risk and reduce the risks of PPM, even in HR patients, with excellent hemodynamics.

Transcatheter Aortic Valve Implantation for Degenerated 19-mm Aortic Bioprosthetic Valve.

BACKGROUND: The valve-in-valve procedure, in which a transcatheter heart valve (THV) is implanted over a prosthetic valve, has been shown to be safe and therapeutically effective, depending on the size of the replacement valve.Methods and Results:We report 3 cases of successful valve-in-valve procedure to replace a degenerated 19-mm stented prosthetic aortic valve. Balloon-expanding THVs were implanted: 20-mm in the 1st case and 23-mm in the next 2. Aortic stenosis was almost completely resolved in all patients, who recovered promptly and without cardiac adverse events. CONCLUSIONS: Using the valve-in-valve procedure for a 19-mm degenerated bioprosthesis was feasible and safe.

889 days of support on hydrodynamic bearing rotation mode of the DuraHeart™ for bridge-to-heart transplantation.

A 49-year-old man with ischemic cardiomyopathy and tricuspid regurgitation underwent a DuraHeart implantation and tricuspid annuloplasty for bridge-to-heart transplantation. On postoperative day 393, the magnetic levitation system suddenly broke down, and the pump system went into hydrodynamic bearing rotation (HD) mode without causing relevant symptoms. The controller was exchanged with one that adapted to the HD mode. No significant hemodynamic changes or indications of hemolysis were observed. On postoperative day 982, the pump temporarily stopped nine times. The patient refused pump exchange despite our strong recommendation for it. After 1283 days of DuraHeart support (889 days in HD mode) without hemolysis or neurologic events, he underwent heart transplantation. The DuraHeart manufacturer's analysis revealed much damage to the insulation and fatigue fractures of the conductors, which had resulted in temporary cessation of function and failure of the magnetic levitation system. This was a rare case of long-term support under the DuraHeart HD mode.

Early Results of Simultaneous Transaortic Transcatheter Aortic Valve Implantation and Total Arterial Off-Pump Coronary Artery Revascularization in High-Risk Patients.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become an alternative procedure for treating aortic stenosis (AS) in patients with advanced age and severe comorbidities. Ischemic heart disease (IHD) is present with AS in 40-50% of patients with typical angina. Considering the high operative mortality and morbidity rates in these patients, hybrid TAVI and off-pump CABG (OPCAB) have become realistic treatment options. METHODS AND RESULTS: Between August 2014 and November 2015, 12 patients were evaluated for simultaneous TAVI and OPCAB. Because of their advanced age and comorbidities these patients were not considered suitable for standard open heart surgery. PCI was also considered unsuitable, because of left anterior descending artery (LAD) proximal lesions and/or high SYNTAX score. TAVI was conducted through a median sternotomy after left internal thoracic artery (LITA) to LAD anastomosis. In 11 cases OPCAB with LITA and composite RA graft was performed using an aorta no-touch technique. Mean age at operation was 81±6.3 years. Average number of distal anastomoses was 2.6. Perivalvular leakage was mild in 3 patients, trivial in 8, and none in 1. There was no conversion to on-pump procedure and no hospital deaths. CONCLUSIONS: Simultaneous transaortic TAVI and OPCAB in high-risk patients with severe AS and IHD is a reasonable option. This method could be an alternative to surgical aortic valve replacement and CABG. (Circ J 2016; 80: 1946-1950).

[Emergency Redo Off-pump Coronary Artery Bypass Surgery after 22 Years in an Elderly; Report of a Case].

An 84-year-old male presented to our hospital with recurrent angina. He had undergone coronary artery bypass with a saphenous vein graft to the left anterior descending branch (LAD) 22 years before. Coronary angiography showed occulusion of the proximal LAD and significant stenosis of the saphenous vein graft. An emergency redo operation was conducted using the left internal thoracic artery for LAD revascularization. The postoperative course was uneventful and the patient was discharged in a week. Emergency redo coronary bypass surgery can be indicated even in octogenarians who are resistant to medical treatment.

[Off-pump Coronary Artery Bypass Surgery Following Aortic Root Replacement for Acute Type A Dissection ; Report of a Case].

A 45-year-old male presented to our hospital with worsening heart failure. Computed tomography coronary angiography revealed total occulusion of the proximal left anterior descending artery (LAD). The patient had a history of acute type A dissection,and had undergone aortic root replacement. Avoiding prosthetic graft injury and bleeding,coronary revasculizaion was accomplished by left anterior thoracotomy using the left internal thoracic artery without cardiopulmonary bypass. The postoperative course was uneventful.

Pericardial synovial sarcoma: a case report and review of the literature.

Primary pericardial synovial sarcoma is a rare disease. We herein report a case of synovial sarcoma that originated in the epicardium. A 13-year-old male visited our hospital with a fever and chest pain. Copious pericardial effusion and a large intrapericardial tumor were detected. An open-chest tumor resection was performed. A solid nodular tumor was observed in the pericardial cavity. The tumor was a polypoid mass that was pedunculated and grew from the inner surface of the pericardium near the origin of the SVC and ascending aorta. Histologically, the tumor cells were uniformly spindle shaped, with an ovoid or oval nucleus, and formed solid, compact sheets and fascicles. A storiform pattern was also observed. Based on the histopathological and immunohistochemical findings, and the fluorescence in situ hybridization detection of rearrangement of the SYT gene, a monophasic synovial sarcoma was diagnosed. We discuss the diagnosis and treatment of this case and review the pertinent literature.

Combined mechanical mitral valve replacement and transmitral myectomy for hypertrophic obstructive cardiomyopathy treatment: An experience of over 20 years.

BACKGROUND: Although transaortic septal myectomy (TASM) is recognized as a standard procedure for treating hypertrophic obstructive cardiomyopathy (HOCM), occasionally the left ventricle (LV) intracavitary gradient remains postoperatively because of this technically demanding procedure. Mitral valve replacement (MVR) is sometimes chosen as an alternative option, but data on its long-term outcomes are lacking. METHODS AND RESULTS: Between 1991 and 2016, 29 patients [age, 14-82 (mean 58.9±15.9) years; 22 female patients (75.9%)] underwent combined mechanical MVR and transmitral myectomy. Of these, six patients had undergone MVR following a second cardiac arrest because of the residual LV outflow gradient or residual mitral regurgitation following TASM. Concomitant TASM was performed in 13 patients. The LV intracavitary gradient at rest assessed by transthoracic echocardiography significantly decreased postoperatively (16.8±19.1mmHg vs. 107.4±52.5mmHg, p<0.0001). Actuarial freedom rates from cardiac death were 92.8%, 89.0%, and 80.1% at 5, 10, and 15 years postoperatively, respectively. Sudden death occurred in three of the four patients who died of late cardiac complications. None of these patients with sudden death had implantable cardioverter-defibrillators. Most patients had maintained their LV end-diastolic dimension at <50mm for 10-15 years postoperatively. Actuarial freedom rates from hospitalization for heart failure were 87.7%, 82.2%, and 54.8% at 5, 10, and 15 years postoperatively, respectively. Occurrence rates of cerebral hemorrhage and infarction were 0.6% per patient-year and 1.3% per patient-year, respectively. CONCLUSIONS: Combined mechanical MVR and myectomy is an effective procedure to eliminate the LV intracavitary gradient in patients with HOCM. Although this procedure remains a viable option in certain situations, optimal medical treatment and close clinical follow-up along with the cooperation between cardiac surgeons and cardiologists are necessary to achieve favorable long-term outcomes.

[A case of cardiogenic embolism, which occurred under appropriate warfarin use, treated with thoracoscopic left atrial appendectomy].

A 74-year-old man with a past medical history of bradycardiac atrial fibrillation and an old cerebral infarction presented with dysarthria. He had been treated with warfarin and PT-INR on admission was 2.0. MRI of the head revealed an acute ischemic stroke involving the cerebellum and left occipital lobe. Because transesophageal cardiac echography showed a thrombus in the left atrial appendage, anticoagulant treatment with warfarin and heparin was initiated. The thrombus was enlarging; therefore, we changed the anticoagulant therapy to apixaban with heparin on day 11. On day 17, a hemorrhagic cerebral infarction occurred. After the hemorrhage diminished, we treated him with warfarin aiming for a PT-INR between 3 and 4. The thrombus gradually shrank and disappeared on day 110. Finally, a thoracoscopic left atrial appendectomy was performed as a secondary prevention, with no recurrence till date.

Functional mitral stenosis after mitral valve repair for Type II dysfunction: determinants and impacts on long-term outcome.

OBJECTIVES: This study was performed to analyse the impacts of functional mitral stenosis (MS) following mitral valve (MV) repair on late cardiac function and new onset of atrial fibrillation or survival. METHODS: We retrospectively reviewed 602 patients with mitral regurgitation who underwent MV repair for Type II dysfunction from 2001. Functional MS was diagnosed when the mean transmitral pressure gradient (MTPG) was ≥5 mmHg on postoperative echocardiography. We analysed preoperative and surgical risk factors for functional MS (MS group). We then compared long-term outcomes and late cardiac function over time between patients in the MS and no-MS groups using a mixed-effects model with repeated measures. RESULTS: On postoperative echocardiography, 51 patients had an MTPG of ≥5 mmHg (MS group) and 551 had an MTPG of <5 mmHg (no-MS group). Only the ring size was an independent predictor of MS (28.8 ± 2.1 mm in the no-MS group vs 28.0 ± 1.9 mm in the MS group, P = 0.004). During follow-up, increases in the tricuspid regurgitation (TR) pressure gradient (PRV-RA) and TR severity over time were significantly greater in the MS group than in the no-MS group (PRV-RA: 0.72 ± 0.16 vs 0.35 ± 0.17 mmHg per year, respectively, P = 0.03; TR severity: 0.072 ± 0.014 vs 0.034 ± 0.015 per year, respectively, P = 0.0113). Moreover, the 10-year rate of new onset of atrial fibrillation was significantly lower in the MS group than in the no-MS group (37.5% vs 16.9%, respectively; log-rank P = 0.003). CONCLUSIONS: Annuloplasty using a small-sized ring in MV repair caused a postoperative high MTPG, which induced an elevation in the pulmonary artery pressure and residual TR grade and causing new onset of atrial fibrillation despite a competent MV.

Late onset of atrial fibrillation in patients undergoing mitral valve repair for type II dysfunction.

BACKGROUND: There are few reports regarding factors related to late-onset of atrial fibrillation (Af) after mitral valve repair, which can compromise long-term outcome. We analyzed the risk factors for late Af after mitral valve repair. METHODS AND RESULTS: Between 2001 and 2015, 318 patients (214 males; median, 57.7 years) underwent mitral valve repair for degenerative mitral insufficiency (MI) without concomitant aortic valve disease in our institute. Patients with a history of paroxysmal or chronic Af preoperatively were excluded. Serial follow-up echocardiography was used to evaluate cardiac function. The follow-up rate was 99%. The mean follow-up period was 6.0±4.1 years. There was no early death and there were nine late deaths. A total of 29 (9.1%) patients developed late Af. Freedom from late Af was 94.0% at 5 years and 82.9% at 10 years. Small ring annuloplasty, left atrial diameter, and pressure half time, which were measured at follow-up echocardiography, were considered as significant (p<0.05) risk factors for late Af. Patients who had late Af developed recurrent MI more frequently than those who did not (p<0.05). CONCLUSIONS: Remodeling of the atrium caused by functional mitral stenosis is important for late Af, as well as recurrent MI. To prevent these problems, avoiding selection of a small ring at primary mitral repair for type II dysfunction and durable repair are required.

Intracranial mycotic aneurysm is associated with cerebral bleeding post-valve surgery for infective endocarditis.

OBJECTIVES: The presence of cerebral haemorrhage (CH) preoperatively is a risk factor of in-hospital cerebrovascular complications post-valve surgery for acute infective endocarditis. However, factors related to cerebrovascular complications in the long term are poorly understood. We reviewed a series of these patients to investigate risk factors of in-hospital and long-term outcomes. METHODS: An institutional series of 148 patients who underwent valve surgery for active infective endocarditis between 2000 and 2016 were enrolled. Patients were divided into 2 groups based on the presence of preoperative CH:CH group (n = 25) and non-CH group (n = 123). Of them, 14 (10%) patients were preoperatively diagnosed with mycotic aneurysm (MA). RESULTS: The 30-day mortality was 5% with no difference between the 2 groups. The 5-year survival rate was 92% in the CH group and 77% in the non-CH group. Freedom from CH at 5 years was 92% in the CH group and 97% in the non-CH group. There was no difference in the postoperative haemorrhage rate between patients who had surgery within 14 days from the onset of CH and those who had surgery after 14 days. Freedom from CH at 5 years was 99% in patients without MA and 71% in those with MA. The presence of MA preoperatively was the only independent risk factor of postoperative CH (P = 0.002). CONCLUSIONS: Valve surgery for acute infective endocarditis is safe, even in patients with CH preoperatively, regardless of the timing of surgery. Patients with intracranial MA are associated with postoperative CH in the hospital and long term.

Irrigation Device Successfully Tests Valve Competence During Minimally Invasive Mitral Valve Repair.

Minimally invasive mitral valve repair has become standard. We hypothesized that reproducible water testing with less air contaminations may help achieve successful repair and prevent air embolism. We used a long shaft irrigation device connected to an infuser pump to water test mitral valve repair in 104 consecutive patients with severe mitral regurgitation due to type II mitral valve dysfunction. All patients underwent mitral valve repair via small right thoracotomy. Water testing was performed by simultaneously monitoring root pressure to confirm valve competence and adequate leaflet coaptation with suitable pressure. Irrigation was stopped when root pressure reached 60 mm Hg. Simultaneous transesophageal echocardiography showed a negligible amount of air introduction. Predischarge echocardiography revealed residual mitral regurgitation of less than or equal to 1 in all patients, and no patient experienced any major adverse event such as stroke or perioperative myocardial infarction. This novel water test allowed us to correctly check mitral valve competence and reduce air contamination.

Simultaneous transcatheter aortic valve implantation and off-pump coronary artery bypass grafting for Takayasu arteritis.

We report a patient who underwent simultaneous transcatheter aortic valve implantation and off-pump coronary artery bypass grafting for Takayasu arteritis with diffuse porcelain aorta. The patient was a 59-year-old female with severe aortic stenosis and regurgitation, as well as both coronary ostial stenosis and porcelain aorta. Bilateral internal thoracic arteries were unavailable due to Takayasu arteritis. Therefore, composite radial artery with in-situ gastroepiploic artery was used as graft material. Radial artery was anastomosed to left anterior descending artery and posterior descending artery sequentially. Surgical procedures were successfully accomplished and major perioperative complications did not occur. .

Long-term outcome of isolated off-pump coronary artery bypass grafting in patients with coronary artery disease and mild to moderate aortic stenosis.

BACKGROUND: The best management strategy for patients with coronary disease and mild to moderate AS requires the clinician to consider the operative risks of isolated coronary artery bypass grafting (CABG) against the risks of untreated aortic stenosis (AS). METHODS: Between 2000 and 2014, isolated off-pump CABG (OPCAB) was performed in 2023 patients. Of these patients, 103 presented with mild or moderate AS (mean age 72.7±6.3 years; 23 females), 96 (93.2%) presented with mild AS and seven (6.8%) presented with moderate AS. We compared the long-term outcome of these 103 patients undergoing isolated OPCAB with 13 patients who presented with moderate AS and coronary artery disease (CAD) and underwent concomitant aortic valve replacement (AVR) and CABG during the same period. RESULTS: Mean number of distal anastomoses was 3.7±0.9 per patient, and early graft patency was 98.9% (365 of 369 grafts). No patient required on-pump CABG or concomitant AVR. There were two in-hospital deaths (1.9%). Cumulative 5- and 10-year survival rates were 78.3% and 56.6%, respectively. The respective 5- and 10-year rates of freedom from severe AS were 38.1% and 0.0% in patients with moderate AS, and 73.2% and 65.4% in patients with mild AS (log-rank test, p<0.01). Twelve patients required subsequent AVR, including eight who underwent transcatheter AVR. There were no significant differences between patients undergoing isolated OPCAB and patients undergoing concomitant AVR and CABG according to cumulative survival rate (log rank test, p=0.78) and freedom from major adverse cardiac and cerebrovascular events (log rank test, p=0.59). CONCLUSIONS: Isolated OPCAB is a reasonable staged strategy in coronary disease with mild AS, as the less invasive option of transcatheter AVR is available later if required.

Comparison of Hemodynamic Performance and Clinical Results with EVAHEART Versus HeartMate II.

This study aimed to compare the hemodynamic performance and clinical results of the EVAHEART and HeartMate II left ventricular assist devices (LVADs). From 2007 to 2016, fourteen patients received EVAHEART and 28 received HeartMate II at our center. Early survival, driveline infection, and neurologic events were evaluated. Hemodynamic performance was evaluated with transthoracic echocardiography and right heart catheterization. Mean follow-up was 35.5 ± 14.8 months for EVAHEART and 29.8 ± 6.5 months for HeartMate II. Survival rates were comparable between the two groups. After 24 months, freedom from driveline infection was 28% with EVAHEART, and 85% with HeartMate II; freedom from neurologic events was 21% with EVAHEART, and 89% with HeartMate II. Serum lactate dehydrogenase was significantly lower with EVAHEART. There was a significantly greater decrease in left ventricular size with HeartMate II. In catheter examination performed 1 month postoperatively, HeartMate II recipients had significantly lower pulmonary capillary wedge pressure and mean pulmonary pressure, despite a comparable cardiac index. Both devices provided excellent clinical results and hemodynamic performance. HeartMate II could be a better choice to avoid driveline infection and neurologic events. Our results suggest that HeartMate II reduced right ventricular afterload. However, further analysis of more cases is required.