Aortomitral angle affects cardiovascular events after mitral valve repair for atrial functional mitral regurgitation.

PURPOSE: This study aimed to elucidate the geometric parameters of the aortomitral (AM) complex affecting postoperative cardiovascular events (CVEs) in patients with atrial functional mitral regurgitation (MR). METHODS: From October 2008 to August 2018, we performed mitral and tricuspid valve repairs in 58 patients with atrial functional MR. We examined the determinants of CVEs using preoperative and postoperative echocardiographic data. Furthermore, we analyzed the effect of left atrial (LA) plication on AM geometries after surgery. The follow-up period ranged from 56 to 3283 days (median, 1073 days). RESULTS: All patients underwent mitral and tricuspid annuloplasty. Seventeen patients (29%) underwent additional LA plication. The AM angle was narrowed after surgery in patients with CVEs (115° ± 6.8° to 106° ± 4.2°, p = .00336), whereas it widened in patients without CVEs (115° ± 7.4° to 118° ± 8.4°, p = .0278). The postoperative AM angle was an independent predictor of postoperative CVEs (p = .000829). LA plication was not a predictor of CVEs; however, it was a predictor of the obtuse postoperative AM angle (p = .0071). CONCLUSIONS: Our results suggest that a narrow postoperative AM angle is an independent predictor of postoperative CVEs. Additional LA plication reduces the sharpening of the AM angle, which may prevent CVEs after mitral valve repair for atrial functional MR.

[Tips for Successful Robot-assisted Mitral Valve Repair].

Robot-assisted valve repair refers to an intervention added to conventional minimally invasive cardiac surgery( MICS), which is covered by national insurance since April 2018. However, currently, this procedure is performed only at a few hospitals, which is attributable to the need for specialized facilities, as well as surgeon-related criteria including high technical expertise. Notably, the learning curve to stabilize robotic surgery is longer than that for conventional MICS. Our hospital introduced robot-assisted valve repair in June 2018, and we have performed >120 surgeries to date. Our policy focuses on "no compromise in the quality of valve repair". The loop technique is routinely used for valve repair, and the experience gained from median sternotomy and MICS is directly applied to robotic procedures. Robot-assisted surgery enhances surgical field visualization and improves operability even in cases of complex valve repair. In this article, I will describe the procedural innovations, secure establishment of cardiopulmonary bypass, surgical outcomes, and the current challenges in robot-assisted valve repair to achieve safe and improved results.

Corynebacterium jeikeium-induced infective endocarditis and perivalvular abscess diagnosed by 16S ribosomal RNA sequence analysis: A case report.

INTRODUCTION: Corynebacterium jeikeium normally presents on human skin, and it is often judged as contamination when it is cultured from blood. C. jeikeium can cause infective endocarditis, especially, that associated with cardiac surgery and prosthetic valvular endocarditis. CASE REPORT: A 66-year-old Japanese male patient was diagnosed with C. jeikeium-induced infective endocarditis (IE) and perivalvular abscess after a coronary artery bypass grafting and aortic valve replacement with bioprosthesis; pyogenic spondylodiscitis was also observed. Patch repair for aortic valve annulus and re-Bentall procedure with bioprosthesis was performed for IE and perivalvular abscess. The causative bacterium was confirmed as C. jeikeium on 16S ribosomal RNA sequencing of surgical sample and positive blood culture. The patient underwent six weeks of intravenous antibacterial treatment with vancomycin and an additional two weeks of oral treatment with linezolid, following which, his condition improved. Corynebacterium jeikeium can cause infective endocarditis and perivalvular abscess, which is a more severe condition than IE. CONCLUSION: 16S ribosomal RNA sequencing is useful in diagnosing bacterial species that can cause contamination, such as Corynebacterium spp.

Loop technique for degenerative mitral regurgitation due to extended prolapse.

PURPOSE: Our study aims to examine the midterm outcomes of the loop technique for extended mitral valve (MV) prolapse patients. METHODS: From October 2008 to August 2020, we performed MV repairs in 407 patients with severe mitral regurgitation (MR). Follow-up ranged in duration from 287 to 2899 days (median, 872 days). The prolapse extensiveness (p-score) was determined based on the ratio of prolapsing segment's areas to whole area. We divided the whole MV into 10 segments (A1, A2 medial, A2 lateral, A3, P1, P2 medial, P2 lateral, P3, AC, and PC). Patients were categorized into three groups according to the p-score: simple (0.1-0.2), intermediate (0.3-0.4), and extensive (0.5-0.9). RESULTS: All patients underwent MV repair with the loop technique. The rates of freedom from significant (moderate to severe or severe) MR at 5 and 7 years after surgery were 91% and 91%, respectively. There were 252, 115, and 40 patients in simple group, intermediate group, and extensive group, respectively. The following were significantly increased in extended group: Barlow disease (23/40 patients, p < .001), the number of loops (p for trend < .0001), and the technique score (p for trend < .0001). The rates of freedom from significant MR at 7 years after surgery were 92% in simple group, 87% in intermediate group, and 94% in extended group, respectively (p = .995). Receiver-operating characteristic curves showed a postoperative mild MR with a sensitivity of 86% and a specificity of 68% for predicting significant MR recurrence. CONCLUSIONS: MV repair using the loop technique was useful even in groups with extended prolapse.

The Impact of Aorto-Mitral Angle on New-Onset Atrial Arrhythmia after Mitral Valve Repair in Patients with Mitral Regurgitation.

In this study, we hypothesized that post-operative aorto-mitral angle might be associated to the occurrence of post-operative atrial arrhythmia (AA), including atrial fibrillation and atrial tachycardia, after mitral valve repair in patients with mitral regurgitation (MR). Thus, this present study aims to determine the effects of post-operative aorto-mitral angle on new-onset AA after mitral valve repair with mitral annuloplasty for the treatment of MR.In total, 172 patients without any history of AA underwent mitral valve repair with mitral annuloplasty in our institution between 2008 and 2017. Patient information, including medical records and echocardiographic data, were retrospectively studied.As per our findings, AA occurred in 15 (8.7%) patients during the follow-up period (median, 35.7 months; range, 0.5-132 months). The patients with AA were noted to have a longer cardiopulmonary bypass time and a smaller aorto-mitral angle at post-operative TTE than the others (119 ± 6° versus 125 ± 10°, P = 0.003). No significant difference was noted in the degree of post-operative residual MR or functional MS between the groups. In a multivariate Cox proportional hazards analysis, the longer cardiopulmonary bypass time and the smaller post-operative aorto-mitral angle were independent predictors of the occurrence of AA during the follow-up period (odds ratio per 10 minutes 1.11; 95% CI 1.02-1.22, P = 0.019: odds ratio 0.91; 95% CI 0.85-0.98, P = 0.012).A small aorto-mitral angle at post-operative TTE was determined to be a predictor of new-onset AA after a mitral valve repair for treating MR.

Starting position effects in the measurement of the postural vertical for pusher behavior.

Pusher behavior (PB) is a severe lateral postural disorder that involves a disturbed subjective postural vertical (SPV) in the frontal plane. SPV is measured by determining the mean value and standard deviation of several trials beginning on both the contralesional- and ipsilesional-tilted positions. However, the postural representation, when passively tilted to the contralesional versus ipsilesional position, is different between patients with and without PB. Therefore, we hypothesized that SPV dependence on the starting position will be influenced by PB. For 53 patients with hemispheric stroke enrolled, SPV was measured using a non-motorized vertical board with eyes closed. The mean value (tilt direction) and standard deviation (variability) were calculated in four trials, each from two positions, with the patient tilted to the contralesional position (SPV-CL condition) and then to the ipsilesional position (SPV-IL condition). Patients were categorized into the non-pusher (n = 29) and pusher (n = 24) groups. In the SPV-CL trials, the tilt direction was significantly tilted contralesionally for the pusher group (- 6.3° ± 1.6°) compared with that for the non-pusher group (- 2.2° ± 1.8°; p < 0.001), with no significant difference in variability between the groups. In the SPV-IL trials, the tilt direction was not significantly different between the groups, but the variability was significantly higher in the pusher group (4.8° ± 2.0°) than in the non-pusher group (2.2° ± 1.3°; p < 0.001). The dependence of tilt direction and variability of SPV on the starting position in patients with PB differed from those noted in patients without PB. These results may help explain this abnormal posture and optimize neurological rehabilitation strategies for PB.

Etiology of Atrial Functional Mitral Regurgitation: Insights from Transthoracic Echocardiography in 159 Consecutive Patients with Atrial Fibrillation and Preserved Left Ventricular Ejection Fraction.

BACKGROUND: Left atrial (LA) dilatation in patients with atrial fibrillation (AF) can induce functional mitral regurgitation (MR) despite a preserved left ventricular ejection fraction (LVEF). The purpose of this study was to investigate the etiology of this functional MR. METHODS: We retrospectively examined clinical and echocardiographic data from 5,202 consecutive cases that underwent transthoracic echocardiography. AF appeared in 544 patients, and we selected 159 with AF and LVEF ≥50% after excluding patients with other underlying heart diseases. RESULTS: Significant (moderate or greater) degrees of functional MR were seen in 13 (8.2%) patients and were more frequently seen in patients with an AF duration of >10 years than in others (27 vs. 4%, p = 0.0057). Multiple regression analysis revealed that both the LA dimension index and the left ventricular (LV) systolic dimension index were independent determinants of the MR grading. Among the mitral morphologic parameters, the mitral annular (MA) dimension index and the hamstringing phenomenon of the posterior mitral leaflet were independent determinants of MR grading. Significant MR was not seen in patients without LA dilatations, but it occurred in 14% of patients with LA dilatation alone and in 55% with both LA and LV dilatations; the MA dimension index increased in this order. CONCLUSIONS: The grading of functional MR occurring in patients with AF and preserved LVEF depends on both the LA dimension and the LV systolic dimension. The MR grading also depends on both the MA dilatation and the hamstringing phenomenon of the posterior mitral leaflet.

Successful Treatment of Staphylococcus schleiferi Infection after Aortic Arch Repair: In Situ Aortic Arch Replacement and Domino Reconstruction of the Debranching Graft using Autologous Iliac Artery.

A 62-year-old Japanese male presented with graft infection by Staphylococcus schleiferi 50 days after debranching of the left subclavian artery and frozen elephant trunk repair for the entry closure of a Stanford type B aortic dissection. The graft was removed, and the patient was successfully treated using in situ reconstruction of the arch with omental flap coverage, removal of the debranching graft, autologous iliac artery grafting, and longterm antibiotics. Domino reconstruction of the infected debranching graft using autologous external iliac artery and a Dacron graft can thus be a good option in similar cases.

Solitary Cardiac Metastasis of Hepatocellular Carcinoma.

Cardiac metastasis originating from hepatocellular carcinoma (HCC) is a rare condition with a poor prognosis. No therapeutic standards for cardiac metastasis originating from HCC have been established. At 19 months after a curative hepatectomy, a 64-year-old Japanese hepatitis B virus-positive male patient experienced solitary cardiac metastasis originating from HCC. The cardiac tumor was discovered in the right ventricle. The patient received three courses of radiotherapy and chemotherapy and survived > 3 years after the initial diagnosis of cardiac metastasis. His case demonstrates that radiotherapy combined with chemotherapy can be an effective treatment for cardiac metastasis.

Prevalence and Prognostic Significance of Functional Mitral and Tricuspid Regurgitation Despite Preserved Left Ventricular Ejection Fraction in Atrial Fibrillation Patients.

BACKGROUND: We investigated the prevalence and prognostic significance of functional mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with atrial fibrillation (AF) and preserved left ventricular ejection fraction (LVEF).Methods and Results:We retrospectively studied the cases of 11,021 consecutive patients who had undergone transthoracic echocardiography. AF appeared in 1,194 patients, and we selected 298 with AF and LVEF ≥50% but without other underlying heart diseases. Moderate or greater (significant) degree of functional MR and of TR was seen in 24 (8.1%) and in 44 (15%) patients, respectively (P=0.0045). In contrast, significant MR and TR were more frequently seen in patients with AF duration >10 years (28% vs. 25%, respectively). During the follow-up period of 24±17 months, 35 patients (12%) met the composite endpoint defined as cardiac death, admission due to heart failure, or mitral and/or tricuspid valve surgery. On Cox proportional hazard ratio analysis, both MR and TR grading predicted the endpoint, independently of other echocardiographic parameters. On Kaplan-Meyer analysis, presence of both significant functional MR and TR was associated with poor prognosis, with an event-free rate of only 21% at the mean follow-up period of 24 months. CONCLUSIONS: Significant functional MR and TR are seen in a substantial proportion of patients with longstanding AF, despite preserved LVEF. This MR/TR combination predicts poor outcome for AF patients, who may have to be treated more intensively.

Enhanced Activity of Immunosuppressive Oligodeoxynucleotides by Incorporating Them into Hexapod-Like Nanostructured DNA.

A151 and other immunosuppressive oligodeoxynucleotides that act as Toll-like receptor (TLR) 9 antagonists are candidate agents for the treatment of autoimmune and inflammatory diseases in which TLR9 activation leads to harmful immune responses. Their efficient delivery to TLR9-positive target cells will increase their potency, but few attempts have been made to enhance their delivery. We previously reported that hexapod-like nanostructured DNA (hexapodna) enhanced the activity of immunostimulatory cytosine-phosphate-guanine (CpG) DNA by efficiently delivering it to immune cells. In this study, to enhance the immunosuppressive activity of A151, we designed a hexapodna containing six copies of the complementary sequence to A151. Structural analyses showed that A151-loaded hexapodna (supHexapodna) was obtained as designed. CpG 1668, which is a typical synthetic CpG DNA, induced tumour necrosis factor-α release from mouse macrophage-like RAW264.7 cells, and supHexapodna inhibited this more efficiently than A151. A flow cytometric analysis showed that the uptake of Alexa Fluor 488-labelled A151 by RAW264.7 cells significantly increased when it was incorporated into supHexapodna, whereas the uptake of Alexa Fluor 488-labelled CpG 1668 was hardly affected by A151 or supHexapodna. These results suggest that the hexapodna-mediated delivery of A151 can increase the potency of its TLR9-inhibitory activity towards immune cells.

Echocardiographic parameters predicting acute hemodynamically significant mitral regurgitation during transfemoral transcatheter aortic valve replacement.

BACKGROUND: Alteration in mitral valve morphology resulting from retrograde stiff wire entanglement sometimes causes hemodynamically significant acute mitral regurgitation (MR) during transfemoral transcatheter aortic valve replacement (TAVR). Little is known about the echocardiographic parameters related to hemodynamically significant acute MR. METHODS AND RESULTS: This study population consisted of 64 consecutive patients who underwent transfemoral TAVR. We defined hemodynamically significant acute MR as changes in the severity of MR with persistent hypotension (systolic blood pressure < 80-90 mm Hg or mean arterial pressure 30 mm Hg lower than baseline). Hemodynamically significant acute MR occurred in 5 cases (7.8%). Smaller left ventricular end-systolic diameter (LVDs), larger ratios of the coiled section of stiff wire tip to LVDs (wire-width/LVDs), and higher Wilkins score were significantly associated with hemodynamically significant acute MR (P < .05), whereas the parameters of functional MR (annular area, anterior-posterior diameter, tenting area, and coaptation length) were not. Moreover, when patients were divided into 4 groups according to wire-width/LVDs and Wilkins score, the group with the larger wire-width/LVDs and higher Wilkins score improved prediction rates (P < .05). CONCLUSIONS: Small left ventricle or wire oversizing and calcific mitral apparatus were predictive of hemodynamically significant acute MR. These findings are important for risk stratification, and careful monitoring using intraoperative transesophageal echocardiography may improve the safety in this population.

Perigraft fluid collection mimicking graft infection in patients with a para-anastomotic aneurysm.

We herein report two cases of perigraft effusion mimicking graft infection after debranching thoracic endovascular repair for an anastomotic pseudoaneurysm of the distal ascending aorta. Both patients presented with a bulging tumor on the sternum. Enhanced computed tomography showed no endoleak, but extension of periprosthetic graft fluid to a subcutaneous sternal wound was present. We suspected a deep sternal wound infection; however, cultures of débrided tissues were negative. After drainage of the subcutaneous fluid or negative pressure wound therapy, both patients were doing well without recurrence of effusion. Endotension was considered to have been associated with enlargement of the perigraft effusion.

Safety and Efficacy of Simultaneous Biplane Mode of 3-Dimensional Transesophageal Echocardiography-Guided Antegrade Multiple-Inflation Balloon Aortic Valvuloplasty in Patients With Severe Aortic Stenosis.

BACKGROUND: Balloon aortic valvuloplasty (BAV) is resurging as a bridge treatment in patients with severe aortic stenosis (AS) with a dissemination of transcatheter aortic valve implantation. However, the significantly high periprocedural mortality and complication rates still limit the indications of BAV. Further efforts are needed to improve the safety and efficacy of BAV.Methods and Results:We retrospectively investigated the safety and efficacy of simultaneous biplane mode of 3-dimensional transesophageal echocardiography (biplane-TEE) guided antegrade transseptal multiple-inflation BAV, with gradual upsizing of the balloon, by enrolling 20 consecutive AS patients who underwent BAV. The median age was 83 years, and there were 6 male patients (30.0%). The clinical frailty scale was 4, and the Society of Thoracic Surgeon score was 14.5%. The balloon was inflated at a median of 18 times, which improved the mean aortic valve pressure gradient from 43.0 to 15.2 mmHg (P<0.001). We safely performed BAV in all patients, without periprocedural death or symptomatic stroke, although asymptomatic stroke was detected in 8 patients (42.1%) on diffusion-weighted magnetic resonance imaging. Kaplan-Meier estimates showed that the survival rate was 84.0% and cardiovascular death-free survival was 88.9% at 1-year. CONCLUSIONS: Biplane-TEE guided antegrade multiple-inflation BAV might have the potential to improve periprocedural survival without increasing complications, compared with conventional retrograde BAV in patients with severe AS.

The effects of aging on the subjective vertical in the frontal plane in healthy adults.

[Purpose] To determine age-related differences in the subjective vertical in the frontal plane in healthy adults. [Subjects and Methods] The subjects were 26 healthy adults. For the subjective visual vertical (SVV), subjects were presented with a visual indicator in front of them that was rotated. For the subjective postural vertical-eyes open (SPV-EO) and subjective postural vertical (SPV), subjects sat in a seating device that was tilted right or left. The subjects gave a signal when they perceived true verticality. Each task was performed eight times. The items examined were the mean (tilt direction) and standard deviation (variability) of the eight trials, then the mean of four trials that started from the right or left side position. These items were compared between the young (age: 22-30 years [range]) and elderly (age: 60-74 years) groups. [Results] As for variability, the elderly group demonstrated significantly higher values of SPV-EO and SPV. As for the starting point effect, the elderly group demonstrated greater bias toward the starting direction than did the young group in SPV-EO and SPV in frontal plane. [Conclusion] The postural vertical was shown to change with age. Consideration of age-related changes and the starting point effect was indicated to be important.

Mitral Valve Replacement with Half-and-Half Technique for Recurrent Mitral Paravalvular Leakage.

Reoperation for paravalvular leakage can cause recurrent paravalvular leakage through severe damage to the mitral annulus. Previously, mitral valve replacement using a half-and-half technique for extensive mitral annular calcification was reported; here, application of the technique to treat recurrent paravalvular leakage is described. A 78-year-old male with three prior mitral valve replacements developed recurrent paravalvular leakage, for which he had undergone his third mitral valve replacement at the age of 69 years. On this occasion, a mechanical valve with circumferential equine pericardial patch reinforcement of the annulus had been used. Five years later, the patient developed hemolytic anemia and congestive heart failure due to recurrent paravalvular leakage. Intraoperatively, broad dehiscence was seen between the prosthetic valve and mitral annulus at two sites, the anterior and posterior commissures, without infection. A fourth mitral valve replacement was performed with a St. Jude Medical valve, using a half-and-half technique. This entailed the use of non-everting mattress sutures on the anterior half of the annulus, and everting mattress sutures on the left atrial wall around the posterior half of the annulus. Extensive annular defects required reinforcement of the posterior mitral annulus with a bovine pericardial patch. Postoperative echocardiography showed no paravalvular leakage. The half-and-half technique may be useful in treating recurrent paravalvular leakage of the mitral valve.

Thermal dewetting behavior of polystyrene composite thin films with organic-modified inorganic nanoparticles.

The thermal dewetting of polystyrene composite thin films with oleic acid-modified CeO2 nanoparticles prepared by the supercritical hydrothermal synthesis method was investigated, varying the nanoparticle concentration (0-30 wt %), film thickness (approximately 50 and 100 nm), and surface energy of silanized silicon substrates on which the composite films were coated. The dewetting behavior of the composite thin films during thermal annealing was observed by an optical microscope. The presence of nanoparticles in the films affected the morphology of dewetting holes, and moreover suppressed the dewetting itself when the concentration was relatively high. It was revealed that there was a critical value of the surface energy of the substrate at which the dewetting occurred. In addition, the spatial distributions of nanoparticles in the composite thin films before thermal annealing were investigated using AFM and TEM. As a result, we found that most of nanoparticles segregated to the surface of the film, and that such distributions of nanoparticles contribute to the stabilization of the films, by calculating the interfacial potential of the films with nanoparticles.

Extended posterior leaflet extension for mitral regurgitation in giant left atrium.

Giant left atrium is a rare condition, with a reported incidence of 0.3%, that is normally caused by rheumatic mitral valve disease but very rarely is caused by other etiologies. In such patients, annular dilatation with tenting and reduced height of the posterior leaflet result in significant mitral regurgitation. At surgery, the posterior leaflet was incised from the posterior mitral annulus, starting the incision at the mid portion of the mitral annulus and, if necessary, extending it to the anterolateral portion of the mitral annulus and the posteromedial portion of the mitral annulus. An autologous pericardial patch was harvested, depending on the incision. Herein is reported a surgical technique for posterior leaflet extension in patients with giant left atrium, without rheumatic disease.

Staged therapeutic surgery for progressive pulmonary regurgitation and pacemaker induced cardiomyopathy after the tetralogy of fallot repair.

BACKGROUND: Recently, improvements in the repair of tetralogy of Fallot have increased the need for reoperation in adulthood, and it's not rare that these reoperation candidates suffer from biventricular failure. However, there are no firm treatment guidelines, and each country, and even each facility, treats each case individually. CASE PRESENTATION: We report the successful staged treatment of pulmonary regurgitation and pacemaker-induced cardiomyopathy with biventricular failure in adulthood in a case of complete atrioventricular block after tetralogy of Fallot repair in childhood. We planned a staged therapeutic strategy with preoperative left ventricular volume reduction with medication, following surgical pulmonary valve replacement concomitant epicardial lead implantation on the lateral basal wall, placed just beneath the generator pocket through 3rd intercostal space. in addition to postoperative intervention with a defibrillator to adjust cardiac resynchronization therapy, resulted in improvement of symptoms. CONCLUSION: In a patient with biventricular failure after TOF repair, a staged treatment strategy involving medication, PVR, and CRT with a combination of epicardial and intravenous leads could be a useful treatment worth trying before heart transplantation.

Surgical repair for a parahiatal hernia with an esophageal hiatal hernia: A case report and literature review.

INTRODUCTION AND IMPORTANCE: A parahiatal hernia (PH) is a rare diaphragmatic hernia (DH) adjacent to but separated from the esophageal hiatus. The surgical repair for PH needs primary suture closure or complicated hernioplasty and the addition of an anti-reflux procedure. This report describes a case of PH with a symptomatic esophageal hiatal hernia managed using three-dimensional (3D) laparoscopy. CASE PRESENTATION: A 65-year-old woman with back pain and breathlessness was referred to our hospital for a DH. Computed tomography showed a diaphragmatic defect on the left side of the esophageal hiatus. Upper gastrointestinal endoscopy and 24-hour esophageal impedance-pH monitoring showed a symptomatic esophageal hiatal hernia. Laparoscopic repair for both hernias was performed using 3D laparoscopy. The DH orifice was located in the left crus of the diaphragm, and it was separated from the esophageal hiatus. These findings showed that this DH was a PH. The PH was repaired with primary suturing, and a hiatoplasty was performed. Toupet fundoplication was performed with a 270° posterior wrap of the gastric fornix. The patient has remained asymptomatic a year after surgery without any complications. CLINICAL DISCUSSION: 3D laparoscopy provides significant advantages in surgeries requiring precise suturing. PH repairs require complex procedures, including mesh repair or suturing. Approximately 44 % of PH cases also necessitate fundoplication. 3D laparoscopy was useful for the present case. CONCLUSIONS: A rare PH and a symptomatic type 1 hiatal hernia were repaired with 3D laparoscopy, which is helpful for PH treatment in cases requiring complicated procedures.