Current status of surgical treatment for acute aortic dissection in Japan: Nationwide database analysis.

OBJECTIVE: To clarify the current status of surgical treatment of acute aortic dissection (AAD) in Japan through the Japan Cardiovascular Database analysis. METHODS: In total, 7194 patients who underwent surgical treatment for AAD in 2021, including type A (TAAAD) (n = 6416) and type B (TBAAD) (n = 778), were investigated. RESULTS: The median age was 70 years, with patients older than age 80 years constituting 21.7% and 23.4% of TAAAD and TBAAD cases. Emergency admission was 88.5% and 78.5%. Shock was found in 11.8% and 6.0%. Rupture/impending rupture occurred in 10.7%/6.0% and 24.0%/11.1%, respectively. Branch malperfusion was complicated in 10.4% and 25.2%. Open repairs were performed in 97.7% and 20.3%, whereas endovascular repairs were performed in 2.3% and 79.7%, respectively. In the increased prevalence of endografting procedures, neurological complications and renal failure occurred frequently after open repair with frozen elephant trunk for 29.9% and 50.3%. The operative mortality rate was 9.8% and 11.5% for open repair and 8.1% and 10.0% for endovascular repair. In patients with TAAAD, age older than 80 years, preoperative critical comorbidities, classical dissection, and coexisting chronic vital organ diseases were independent risk factors for mortality. In frozen elephant trunk procedures, neurologic complications and renal failure were frequent. The operative mortality was higher during the superacute phase within 1 or 2 hours from onset to arrival and between arrival and surgery. CONCLUSIONS: The current status of surgical treatments for AAD including the increased prevalence of endografting of thoracic endovascular aortic repair and frozen elephant trunk were demonstrated with favorable outcomes in the Japan Cardiovascular Database analyses.

Preoperative planning for transaortic septal myectomy using cardiac computed tomography in patients with subaortic septal hypertrophy associated with aortic stenosis: case series.

Background: Electrocardiogram-gated cardiac computed tomography (CT) imaging enables a more accurate understanding of the patient's cardiac anatomy. Preoperative planning for transaortic septal myectomy (TASM), based on cardiac CT, may be useful in patients with subaortic septal hypertrophy associated with severe aortic stenosis (AS). Case summary: Two elderly patients (age >80 years) with subaortic septal hypertrophy associated with AS underwent surgical aortic valve replacement (SAVR) and concomitant TASM after preoperative planning based on cardiac CT. Both patients showed subaortic septal hypertrophy with blood flow acceleration, left ventricular (LV) hypercontractility, and a short distance from the coaptation point of the mitral valve to the septum, resulting in possible dynamic LV outflow tract (LVOT) obstruction after resolution of AS. Optimal mid-diastolic images, selected from the 70-80% phase, were used for preoperative TASM planning. Planned sizes for myectomy based on multi-planar reconstruction were 10 × 26 × 9 mm (width × length × depth) and 10 × 25 × 9 mm for patient 1 and 2, respectively, while resected tissue size was 10 × 24 × 8 mm and 9 × 24 × 8 mm in patient 1 and 2, respectively. After TASM procedure, SAVR was performed with bioprosthetic valve. Postoperative course of both patients was uneventful with no evidence of complete atrioventricular block, septal perforation, or blood flow acceleration at the LVOT. Discussion: Preoperative planning based on cardiac CT images is safe and useful for guiding adequate myectomy and preventing associated complications in patients with subaortic septal hypertrophy associated with AS.

Predictors of procedural complications in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

BACKGROUND: Balloon pulmonary angioplasty (BPA) is an effective treatment for inoperable chronic thromboembolic pulmonary hypertension, with good results reported for residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). However, BPA is associated with complications, such as pulmonary artery perforation and vascular injury, which can lead to critical pulmonary hemorrhage requiring embolization and mechanical ventilation. Furthermore, the risk factors for occurrence of complications in BPA are unclear; therefore, this study aimed to evaluate predictors of procedural complications in BPA. METHODS: In this retrospective study, we collected clinical data (patient characteristics, details of medical therapy, hemodynamic parameters, and details of the BPA procedure) from 321 consecutive sessions involving 81 patients who underwent BPA. Procedural complications were evaluated as endpoints. RESULTS: BPA for residual PH after PEA was performed in 141 sessions (43.9 %), which involved 37 patients. Procedural complications were observed in 79 sessions (24.6 %), including severe pulmonary hemorrhage requiring embolization in 29 sessions (9.0 % of all sessions). No patients experienced severe complications requiring intubation with mechanical ventilation or extracorporeal membrane oxygenation. Age ≥ 75 years and mean pulmonary artery pressure ≥ 30 mmHg were independent predictors of procedural complications. Residual PH after PEA was a significant predictor of severe pulmonary hemorrhage requiring embolization (adjusted odds ratio, 3.048; 95 % confidence interval, 1.042-8.914, p = 0.042). CONCLUSIONS: Older age, high pulmonary artery pressure, and residual PH after PEA increase the risk of severe pulmonary hemorrhage requiring embolization in BPA.

Hemostatic protocol and risk-reduction surgery for treating coronary artery disease with aortic stenosis in a patient with combined coagulation factor VIII and XI deficiency: a case report.

Background: Cardiac surgery remains a significant challenge in patients with coagulation factor VIII (FVIII) deficiency, especially in those with multiple factor deficiencies. Case summary: A 79-year-old man with combined FVIII and factor XI (FXI) deficiency was admitted for heart failure treatment. Transthoracic echocardiography revealed aortic stenosis (AS) with decreased left ventricular ejection fraction (LVEF) of 40%, mean aortic pressure gradient of 21 mmHg, and aortic valve area of 0.58 cm2. Coronary angiography revealed significant triple-vessel disease. The patient had multiple comorbidities, including diabetic end-stage renal disease treated with hemodialysis and liver cirrhosis (Child-Pugh score of A). Considering the high surgical risk, a two-stage treatment strategy was developed: the first with off-pump coronary artery bypass grafting (CABG), and the second with transcatheter aortic valve implantation if AS symptoms were significant after CABG. A perioperative hemostatic protocol by the author's heart team was used to appropriately replenish recombinant FVIII concentrates and fresh frozen plasma. The target preoperative and postoperative FVIII coagulation activity values were set at 80-100% and 60-80%, respectively, whereas the target perioperative FXI coagulation activity value was set at 30-45%. Off-pump CABG without aortic manipulation was completed without bleeding events. Transthoracic echocardiography conducted 20 months postoperatively revealed LVEF of 65% and mean aortic pressure gradient of 31 mmHg. The patient leads a normal life 21 months after surgery. Discussion: The hemostatic protocol and risk-reduction surgery provided satisfactory surgical results in a patient with significant coronary artery disease and AS, high-surgical-risks, and combined FVIII and FXI deficiency.

Balloon pulmonary angioplasty followed by pulmonary endarterectomy: Combination treatment for high-surgical-risk patients with chronic thromboembolic pulmonary hypertension.

OBJECTIVES: Our goal was to evaluate the combined effects of balloon pulmonary angioplasty (BPA) followed by pulmonary endarterectomy (PEA) to treat high-surgical-risk patients with chronic thromboembolic pulmonary hypertension (CTEPH). METHODS: This study included 58 patients with CTEPH who had pulmonary vascular resistance of ≥1000 dyn·s/cm5, mean pulmonary arterial pressure (mPAP) of ≥45 mmHg or mPAP of 38-44 mmHg with comorbidities. Of these, 21 patients underwent the combined therapy of BPA followed by PEA (BPA group) and 37 underwent direct PEA (non-BPA group). Preoperative and postoperative results were compared between the 2 groups. An early postoperative composite event comprised the postoperative use of extracorporeal membrane oxygenation or intra-aortic balloon pump, in-hospital death, rescue BPA, prolonged ventilation, tracheostomy, prolonged stay in the intensive care unit, deep sternal wound infection and cerebral infarction. RESULTS: Before the first intervention (before BPA or direct PEA), patients in the BPA group had a higher mPAP than those in the non-BPA group. After undergoing BPA before PEA, the BPA group demonstrated significantly decreased mPAP and pulmonary vascular resistance (43 vs 52 mmHg, P < 0.001; 636 vs 965 dyn·s/cm5, P = 0.003, respectively) and significantly increased cardiac output (4.1 vs 3.5 l/min, P = 0.041). Notably, the number of patients with the early postoperative composite event was significantly lower in the BPA group than in the non-BPA group (4.8% vs 35.1%, P = 0.011). CONCLUSIONS: Compared with direct PEA, the combination therapy of BPA followed by PEA can be a feasible and effective risk-reduction strategy for high-surgical-risk patients with CTEPH.

Additional survival benefit of bilateral in situ internal thoracic artery grafting with composite radial artery graft in total arterial off-pump coronary artery bypass grafting.

OBJECTIVE: This study aimed to elucidate whether the use of bilateral internal thoracic arteries (BITAs) confers additional survival benefits compared with a single internal thoracic artery (SITA) in total arterial grafting with the radial artery. METHODS: Between 2002 and 2016, 617 patients underwent a bilateral in situ internal thoracic artery grafting with the radial artery as a composite I-graft (BITA-I group) and 516 patients underwent single in situ internal thoracic artery grafting with the radial artery as a composite Y-graft (SITA-Y group). All anastomoses were performed without cardiopulmonary bypass and aortic manipulation. Propensity score matching was performed to adjust covariates and compared the outcomes between the 2 groups. Subanalysis was also performed to evaluate the effects of the BITA-I group on survival according to the covariates using Cox proportional hazards regression analysis. RESULTS: Propensity score matching yielded 348 well-matched pairs. Early postoperative outcomes were similar in the 2 groups. The BITA-I group showed significantly better survival than the SITA-Y group (79.3% vs 70.2% at 10 years, P = .015). The subanalysis revealed a significantly better survival in the BITA-I group among overall patients (hazard ratio, 0.68; 95% confidence interval, 0.49-0.93). There was a significant positive effect on survival in the BITA-I group among patients without comorbidities or those aged <77 years. CONCLUSIONS: BITA grafting with the radial artery provides better long-term survival than SITA grafting with the radial artery, which is enhanced among patients aged <77 years with minimum comorbidities.

15-year outcomes of the JOCRI study (JOCRIED study): a randomised comparison of off-pump and on-pump multiple arterial coronary revascularisation.

OBJECTIVE: The Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) study reported a non-significant difference in early outcomes and graft patency between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting in 2005. The JOCRIED study aimed to review the long-term outcomes of the JOCRI study participants. METHOD AND RESULTS: The JOCRIED study enrolled 123 of the JOCRI study participants completing the clinical follow-up between August 2018 and August 2020; 61 patients in the off-pump group and 62 patients in the on-pump group. The follow-up period was 13.8 ± 2.8 years. The groups were compared regarding mortality, the incidence of major adverse cardiac and cerebrovascular events and repeat revascularisation. The 15-year cumulative survival rate (off-pump vs on-pump, respectively; 77.7% vs 75.3%; p = 0.85), major adverse events-free survival rate (62.5% vs 55.6%; p = 0.27) and repeat revascularisation-free rate (84.8% vs 78.0%; p = 0.16) were not significantly different between the two groups. Revascularisation was the most common major adverse events in the JOCRIED participants. Although percutaneous coronary intervention was performed in 8 patients (13%) in the off-pump group and in 14 patients (23%) in the on-pump group (p = 0.23), no patients underwent redo coronary artery bypass grafting. CONCLUSIONS: Off-pump coronary artery bypass grafting provides comparable 15-year outcomes to on-pump coronary artery bypass grafting.

Efficacy of Off-Pump Coronary Artery Bypass Grafting With Concomitant Transcatheter Aortic Valve Replacement.

AIM: This study aimed to evaluate the early and intermediate-term outcomes of patients who underwent concomitant off-pump coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR). METHOD: Between January 2014 and June 2021, 49 patients underwent concomitant off-pump CABG and TAVR via median sternotomy (TAVRCAB group) and 143 underwent concomitant on-pump CABG and surgical aortic replacement. Of the 143 patients who underwent on-pump surgery, 80 (SAVRCAB group) were eligible for comparison. The composite event included all-cause death, heart failure rehospitalisation, repeat revascularisation, brain infarction, and repeat aortic valve replacement. RESULTS: The Society of Thoracic Surgeons' predicted risk for mortality and age were higher in the TAVRCAB group than in the SAVRCAB group (7.1% vs 3.1% [p<0.001]; 81 yrs vs 75 years [p<0.001], respectively), while the surgical time was shorter (289 min vs 352 min; p<0.001). There was no conversion to on-pump surgery in the TAVRCAB group. The postoperative maximum creatinine kinase-MB value was lower in the TAVRCAB group. There was no deep sternal wound infection or repeat revascularisation in either group. Hospital death and brain infarction developed in one patient (1.3%) each in the SAVRCAB group, but in no patients in the TAVRCAB group. The rates of freedom from the composite event were similar between the two groups during the follow-up period. CONCLUSIONS: Concomitant off-pump CABG and TAVR would be a less-invasive alternative procedure for treating intermediate or high surgical risk patients with aortic stenosis and coronary artery disease unsuitable for percutaneous coronary intervention.

Coronary artery aneurysms of unknown origin in a 14-year-old girl.

The case of a 14-year-old girl with acute myocardial infarction due to coronary artery aneurysms (CAAs) of unknown origin, which resembled coronary artery lesions caused by Kawasaki disease, is reported. She was transferred to our hospital due to chest pain with ST-T elevation. She had no history of Kawasaki disease. On the first admission, she was misdiagnosed with acute myocarditis. Then, 54 days later, she experienced chest pain with exertional dyspnea. Her electrocardiogram showed negative T waves in the chest leads. A CAA of the left coronary artery was suspected on two-dimensional echocardiography. Coronary angiograms showed 90% stenosis and multiple CAAs of the left anterior descending artery and the bifurcation of the left coronary artery. Both the right coronary artery and left circumflex artery were occluded. A left ventriculogram showed dyskinesis and an aneurysm at the apex. She underwent triple-vessel coronary artery bypass grafting, and her symptoms improved. In addition, an intracranial aneurysm was also found on cerebral angiography. There were no specific laboratory findings other than SS-A antibodies. It was suspected that the weakness of the vessels was related to the disease. It may have been a different disease that was never previously detected, but her CAAs were Kawasaki-like CAAs.

Left coronary ostial stenosis developing 15 months after transcatheter aortic valve replacement with balloon-expandable valve.

We present the case of an 82-year-old man whose left coronary ostium became obstructed 15 months after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve. The patient underwent TAVR for symptomatic severe aortic stenosis with no complications. Fifteen months after the initial TAVR, the patient complained of chest pain while exercising, and the exercise stress myocardial perfusion scintigraphy demonstrated the development of regional myocardial ischemia in the region of the left coronary artery. Coronary angiography implied severe stenosis in the ostium of the left coronary artery. Computed tomography angiography and intravascular ultrasonography indicated a soft tissue component along with stent struts, which was considered to cause delayed coronary obstruction. Our report emphasizes the importance of having a low threshold for clinically suspecting delayed coronary obstruction in patients who have undergone TAVR, even after several years of the procedure. .

Emergency sandwich patch repair via right ventricular incision for postinfarction ventricular septal defects: a case series.

BACKGROUND: The surgical treatment for postinfarction ventricular septal defect (VSD) remains challenging, especially in emergency cases. Several authors have reported the efficacy of a sandwich patch VSD repair via a right ventricular (RV) incision. However, this procedure remains uncommon, and its efficacy is still unknown, especially when performed under an emergency. CASE SUMMARY: We were able to perform sandwich patch VSD repair via an RV incision on seven consecutive patients with VSD following an ST-segment elevation myocardial infarction (STEMI) from March 2017 to December 2019. Bovine pericardial patches were used for sandwich patches. Two patients developed inferior STEMI, and the other patients developed anterior STEMI. Six patients received intra-aortic balloon pump prior to surgery, and the other received extracorporeal membrane oxygenation with Impella. The interval between the diagnosis of VSD and surgery was within 1 day in all patients except one (5 days). All seven patients underwent VSD repair in the emergency status. Four patients underwent concomitant coronary artery bypass grafting. The hospital mortality rate was 14.3% (1/7). Early postoperative transthoracic echocardiography revealed that only one patient developed more than trace residual shunt. The postoperative right atrial pressure was not significantly elevated at ≤12 mmHg in all patients. No patient developed early postoperative prolonged low cardiac output syndrome. DISCUSSION: In patients with postinfarction VSD, a sandwich patch VSD repair via an RV incision is a promising procedure with a low incidence of residual shunt development and hospital mortality, even in emergency cases.

Reverse remodelling after aortic valve replacement for chronic aortic regurgitation.

OBJECTIVES: This study aimed to assess the long-term outcomes and investigate the factors related to left ventricular (LV) reverse remodelling after aortic valve replacement (AVR) in patients with chronic aortic regurgitation (AR). METHODS: A total of 246 patients who underwent AVR for chronic AR at our institution were included in this retrospective study. Primary end-points included all-cause mortality, cardiac mortality and major adverse cerebral and cardiovascular events. Secondary end-points included cardiac function on echocardiography 1 year after surgery. We explored the predictive factors for reverse remodelling 1 year after surgery. RESULTS: The 10-year survival rate was 86.0%, with no cardiac deaths in 93.8% and no major adverse cerebral and cardiovascular events in 79.9% of patients. Postoperative LV function and symptoms were significantly improved 1 year after surgery, but 34 patients (13.8%) did not recover normal function and structure. A significant negative correlation was found between the incidence of cardiac death and major adverse cerebral and cardiovascular events and reverse remodelling. Multivariate logistic regression identified preoperative LV ejection fraction (P = 0.001, odds ratio = 1.057) and LV end-systolic dimension index (P = 0.038, odds ratio = 0.912) as significant predictive factors of reverse remodelling 1 year after surgery. CONCLUSIONS: Preoperative LV ejection fraction and LV end-systolic dimension index were predictive factors for reverse remodelling after surgery, which was associated with late outcomes. Earlier surgery may thus help to restore normal LV function and achieve better late outcomes after AVR for AR.

Surgical exclusion of an idiopathic saccular aneurysm in the left main trunk of the coronary artery.

PURPOSE: A coronary artery aneurysm (CAA) can result in critical cardiac events such as thromboembolic complications or rupture. A saccular CAA located in the left main trunk (LMT) is the most critical form of this pathology and its surgical repair is challenging. We conducted this single-center study to review the surgical outcomes of patients with a saccular CAA in the LMT. METHODS: Between May, 2012 and June, 2020, five patients with a saccular CAA in the LMT underwent surgery at our center. The median age at operation was 66.5 (59.7-69) years and the median diameter of the CAA was 13.0 mm (IQR 11-14 mm). RESULTS: The CAA was fully excluded by patch closure of the LMT orifice and direct closure of the distal LMT, supplemented by coronary artery bypass grafting with the exclusive use of arterial conduits. There was no in-hospital mortality, although one patient suffered graft spasm-related myocardial infarction with complete recovery. Post-operative angiography showed a fully excluded LMT in all patients. There was no mortality or adverse cardiac events during follow-up. CONCLUSIONS: Our surgical policy for CAA in the LMT is feasible and safe; however, coronary blood flow is dependent on reliable bypasses.

Reverse left ventricular remodelling after aortic valve replacement for severe aortic insufficiency.

OBJECTIVES: The goal of this study was to investigate the long-term outcome of aortic valve replacement (AVR) for severe aortic insufficiency with a focus on pre- and postoperative left ventricular (LV) function to explore predictive factors that influence the recovery of LV function and clinical outcome. METHODS: A total of 478 patients who underwent AVR for pure severe aortic insufficiency were grouped according to the preoperative echocardiographical LV ejection fraction (EF): low (LO) EF <35% (n = 43), moderate EF 35-50% (n = 150) or normal EF >50% (n = 285). RESULTS: Actuarial survival at 10 years post-AVR was 64% with a LO EF, 92% with a moderate EF and 93% with a normal EF (P = 0.016), whereas 10-year rates of freedom from major adverse cerebral and cardiovascular events were 47%, 79% and 84%, respectively (P < 0.0001). Echocardiography at 1 year post-AVR demonstrated that EF substantially improved in all groups. We noted a significant difference in survival (P = 0.0086) and in freedom from major adverse cerebral and cardiovascular events (P = 0.024) between patients with an EF ≥35% and those with an EF <35% in the LO EF group. The multivariable logistic regression model showed that predictive factors for lack of improvement in EF 1 year post-AVR in the LO EF group included plasma brain natriuretic peptide >365 pg/mL (P = 0.0022) and echocardiographic LV mass index) >193 g/m2 (P = 0.0018). CONCLUSIONS: Long-term outcome post-AVR for severe aortic insufficiency was largely influenced by preoperative LV function. Predictive factors of failure to recover ventricular function post-AVR included EF <25%, pre-brain natriuretic peptide >365 pg/mL or LV mass index >193 g/m2.

Comparison of safety and haemodynamic performance between the Avalus™ stented aortic valve bioprosthesis and Magna™ valve in Japanese patients.

OBJECTIVES: A new stented bovine pericardial valve (Avalus™) has been proven safe and effective with good hemodynamic performance in Western populations. However, its use in Japanese patients is poorly understood. We retrospectively compared the feasibility, safety, and valve haemodynamics between the Avalus™ and Magna™ valves in patients who underwent surgical aortic valve replacement (SAVR). METHODS: This study included 87 patients receiving an Avalus™ valve and 387 receiving a Magna™ valve. We evaluated adverse events, outcomes, and valve haemodynamics within 1 year postoperatively. There were no significant differences in any surgical risk scores. RESULTS: No in-hospital mortality occurred in the Avalus™ group, but two mortality events occurred in the Magna™ group. No pacemaker implantation for complete atrioventricular block was required in the Avalus™ group. There was no significant difference in in-hospital or clinical outcomes between the two groups until 1 year postoperatively. Left ventricular mass index reduction appeared to predominate in the Avalus™ over Magna™ group. There was no significant difference in the mean pressure gradient or effective orifice area of each valve size at 1 week or 1 year between the two groups, apart from the mean pressure gradient of the 23-mm valve at 1 week. Three patients (3.4%) in the Avalus™ group and 39 (10.8%) in the Magna™ group (p = 0.12) had severe patient-prosthesis mismatch at 1 week postoperatively. CONCLUSIONS: The new Avalus™ stented aortic valve bioprosthesis was associated with good in-hospital outcomes and good valve functionality post-SAVR in Japanese patients.

Benefits of robotically-assisted surgery for complex mitral valve repair.

OBJECTIVES: To determine whether robotic mitral valve repair can be applied to more complex lesions compared with minimally invasive direct mitral valve repair through a right thoracotomy. METHODS: We enrolled 335 patients over a 9-year period; 95% of the robotic surgeries were performed after experience performing direct mitral valve repair. RESULTS: The mean age in the robotic versus thoracotomy repair groups was 61 ± 14 vs 55 ± 11 years, respectively (P < 0.001); 97% vs 100% of the patients, respectively, had degenerative aetiologies. Repair complexity was simple in 106 (63%) vs 140 (84%), complex in 34 (20%) vs 20 (12%) and most complex in 29 (17%) vs 6 (4%) patients undergoing robotic versus thoracotomy repair, respectively. The average complexity score with robotic repair was significantly higher versus thoracotomy repair (P < 0.001). The robotic group underwent more chordal replacement using polytetrafluoroethylene and less resections. All patients underwent ring annuloplasty. Cross-clamp time did not differ between the groups, and no strokes or deaths occurred. More patients undergoing robotic repair underwent concomitant procedures versus the thoracotomy group (30% vs 14%, respectively; P < 0.001). The overall repair rate was 100%, with no early mortality or strokes in either group. Postoperative mean residual mitral regurgitation was 0.3 in both groups, and the mean pressure gradient through the mitral valve was 2.4 vs 2.7 mmHg (robotic versus thoracotomy repair, respectively; P = 0.031). CONCLUSIONS: Robotic surgery can be applied to repair more complex mitral lesions, with excellent early outcomes.

Sex differences in continuous-flow ventricular assist device therapy for advanced heart failure.

OBJECTIVE: The effect of patient sex in continuous-flow ventricular assist device (c-VAD) therapy has not been well described. We investigated sex-specific differences in clinical outcomes related to c-VAD therapy for Japanese patients. METHODS: We retrospectively analyzed 153 patients, including 41 (27%) female patients who underwent c-VAD implantation over the last 13 years in our institution for a mean follow-up of 766 ± 446 days. Clinical outcomes were compared between male and female patients RESULTS: There was no significant difference in mortality, cerebral vascular accidents, the severity of heart failure, or driveline infection in patients who underwent c-VAD implantation, regardless of sex. While male patients tended to have more bleeding at the time of surgery, female patients had significantly higher rates of non-surgical bleeding during subsequent c-VAD therapy, mainly from gynecological origins. CONCLUSIONS: Female patients treated with c-VAD had a significantly higher incidence of non-surgical bleeding events. Careful attention to gynecological complications and sex-specific care is required in female patients with c-VAD.

Long-term outcomes after reoperation for mitral paravalvular leaks: a single-centre experience.

OBJECTIVES: We aimed to analyse the pathology of paravalvular leak (PVL), and determine the long-term outcomes of redo mitral valve replacement and risk factors of all-cause mortality. METHODS: Seventy-nine patients (mean age 70 ± 9 years; 54 female, 68%) who underwent redo mitral valve replacement for mitral PVL between January 2000 and May 2019 were retrospectively reviewed. Indications for PVL intervention were haemolytic anaemia (57/79, 72%), New York Heart Association class III/IV congestive heart failure (56/79, 71%) and prosthetic valve endocarditis with PVL (2/79, 3%). RESULTS: PVL most commonly occurred at lateral sectors (42/79, 55%). Early mortality occurred in 2 patients (3%) due to low cardiac output syndrome. Two patients (3%) had residual PVL at discharge. Sixteen patients (23%) developed late PVL (mean follow-up, 3.4 ± 2.9 years), among whom 11 (69%) developed PVL at same area as that preoperatively. Additionally, 9 patients (56%) developed PVL at lateral sectors in late follow-up. At 1, 5 and 10 years, the survival rate was 93%, 72% and 45%; rate of freedom from cardiac death was 96%, 92% and 78%; and rate of freedom from PVL recurrence was 94%, 82% and 54%, respectively. Chronic kidney disease was the only risk factor in the multivariate analysis for mortality [P = 0.013; hazard ratio 4.0 (1.4-11.0)]. CONCLUSIONS: Surgery for mitral PVL confers reasonable early and long-term outcomes. Greater attention to the anterolateral annulus may help prevent PVL.

Early results of robotically assisted mitral valve repair in a single institution: report of the first 100 cases.

OBJECTIVE: Robotically assisted mitral valve repair was approved for use in Japan in April 2018. The study objective was to assess the safety and clinical outcomes of robotic mitral valve surgery in the first 100 cases performed in our center. METHODS: We reviewed the first 100 patients who underwent robotic primary mitral valve repair, including concomitant procedures, from April 2018 to August 2019. The cause of mitral valve disease was degenerative (n = 94), endocarditis (n = 2), functional (n = 2), and other (n = 2). RESULTS: There was no in-hospital or 30-day mortality. Mitral valve repair was completed in all patients. Only one patient required conversion to full sternotomy due to left ventricular apex bleeding. In echocardiography performed before hospital discharge, the mitral regurgitation was graded as none or trivial in 94 patients (94%) and mild in 4 (4%). Only two patients required surgical re-intervention due to postoperative hemolysis with moderate mitral regurgitation. For patients who underwent the mitral valve procedure alone, the median times of the total operation, cardiopulmonary bypass, aortic clamping, and console usage were 185, 112, 71, and 60 min, respectively. The learning curve showed that the operation time decreased slightly during the first ten cases and then plateaued at a mean of approximately 180 min. CONCLUSIONS: Robotically assisted mitral valve repair was feasible, safe, and therapeutically effective in the first 100 cases, with a minimal learning curve. The robotically assisted approach provides a high-quality surgical view and tremorless suture/cut handling, which will contribute to further development of minimally invasive mitral valve surgery.

Central conversion from peripheral extracorporeal life support for patients with refractory congestive heart failure.

Conversion from peripheral extracorporeal life support (ECLS) to the central one can improve and stabilize hemodynamics in patients with refractory congestive heart failure-related multiorgan failure, whereas indication and selection of the type of the central ECLS have not been fully established. Institutional outcome of the conversion therapy was herein reviewed to verify indication and selection of three types of central ECLS. This study enrolled an institutional consecutive surgical series of 24 patients with refractory congestive heart failure under peripheral ECLS, related to fulminant myocarditis (n = 15), dilated cardiomyopathy (n = 5), or acute myocardial infarction (n = 4). They were converted to central Y-extracorporeal membrane oxygenation (ECMO, n = 6), extracorporeal ventricular assist device (EC-VAD, n = 12), or pump catheter (n = 6), dependent upon the degree of multiorgan failure. Despite the different degree of multiorgan failure prior to the conversion, improvement in end-organ perfusion and reduction in right atrial and pulmonary artery pressure were promptly achieved regardless of the type of the central ECLS. There were five in-hospital mortalities (21%) during the central ECLS, whereas mechanical support was weaned-off in 11 cases (46%) and durable LVAD was subsequently implanted for bridge to transplantation in eight cases (33%). Conversion from the peripheral ECLS to the central ones, such as central Y-ECMO, EC-VAD or pump catheter, promptly established a sufficient support with heart and lung unloading in patients with refractory congestive heart failure.