Outcomes of Concomitant Maze Procedure in Tricuspid Repair for Severe Tricuspid Regurgitation.

BACKGROUND: We aimed to analyze the impact of concomitant Maze procedure on the clinical and rhythm outcomes, and echocardiographic parameters in tricuspid repair for patients with severe tricuspid regurgitation (TR) and persistent atrial fibrillation (AF). METHODS: Patients who had severe TR and persistent AF and underwent tricuspid valve (TV) repair were included in the study. Both primary TR and secondary TR were included in the current study. The study population was stratified according to Maze procedure. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE) at 15 years post-surgery. Propensity-score matching analyses was performed to adjust baseline differences. RESULTS: Three hundred seventy-one patients who underwent tricuspid repair for severe TR and persistent AF from 1994 to 2021 were included, and 198 patients (53.4%) underwent concomitant Maze procedure. The maze group showed 10-year sinus rhythm (SR) restoration rate of 55%. In the matched cohort, the maze group showed a lower cumulative incidence of cardiac death (4.6% vs. 14.4%, P = 0.131), readmission for heart failure (8.1% vs. 22.2%, P = 0.073), and MACCE (21.1% vs. 42.1%, P = 0.029) at 15 years compared to the non-maze group. Left atrial (LA) diameter significantly decreased in the maze group at 5 years (53.3 vs. 59.6 mm, P < 0.001) after surgery compared to preoperative level, and there was a significant difference in the change of LA diameter over time between the two groups (P = 0.013). CONCLUSION: The Maze procedure during TV repair in patients with severe TR and persistent AF showed acceptable SR rates and lower MACCE rates compared to those without the procedure, while also promoting LA reverse remodeling.

Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation: Current Status in Korea.

BACKGROUND: In the era of transcatheter aortic valve implantation, this study was conducted to investigate the current trend of aortic valve procedures in Korea and to evaluate the early and mid-term outcomes of isolated surgical aortic valve replacement (SAVR) using bioprosthetic valves in contemporary Korea. METHODS: Contemporary outcomes of isolated bioprosthetic SAVR in Korea were analyzed using the datasets on a multicenter basis. Patients who underwent isolated SAVR using bioprostheses from June 2015 to May 2019 were included, and those with concomitant cardiac procedures, SAVR with mechanical valve, or SAVR for infective endocarditis were excluded. A total of 456 patients from 4 large-volume centers were enrolled in this study. Median follow-up duration was 43.4 months. Early postoperative outcomes, mid-term clinical outcomes, and echocardiographic outcomes were evaluated. RESULTS: Mean age of the patients was 73.1 ± 7.3 years, and EuroSCORE II was 2.23 ± 2.09. The cardiopulmonary bypass time and aortic cross-clamp times were median 106 and 76 minutes, respectively. SAVR was performed with full median sternotomy (81.8%), right thoracotomy (14.7%), or partial sternotomy (3.5%). Operative mortality was 1.8%. The incidences of stroke and permanent pacemaker implantation were 1.1% and 1.1%, respectively. Paravalvular regurgitation ≥ mild was detected in 2.6% of the patients. Cumulative incidence of all-cause mortality at 5 years was 13.0%. Cumulative incidences of cardiovascular mortality and bioprosthetic valve dysfunction at 5 years were 7.6% and 6.8%, respectively. CONCLUSION: The most recent data for isolated SAVR using bioprostheses in Korea resulted in excellent early and mid-term outcomes in a multicenter study.

Coronary Microcirculatory Dysfunction and Acute Cellular Rejection After Heart Transplantation.

BACKGROUND: Acute cellular rejection is a major determinant of mortality and retransplantation after heart transplantation. We sought to evaluate the prognostic implications of coronary microcirculatory dysfunction assessed by index of microcirculatory resistance (IMR) for the risk of acute cellular rejection after heart transplantation. METHODS: The present study prospectively enrolled 154 heart transplant recipients who underwent scheduled coronary angiography and invasive coronary physiological assessment 1 month after transplantation. IMR is microcirculatory resistance under maximal hyperemia. By measuring hyperemic mean transit time using 3 injections (4 mL each) of room-temperature saline under maximal hyperemia, IMR was calculated as hyperemic distal coronary pressure×hyperemic mean transit time. The primary end point was biopsy-proven acute cellular rejection of grade ≥2R during 2 years of follow-up after transplantation and was compared by using multivariable Cox proportional hazards regression according to IMR. The incremental prognostic value of IMR, in addition to the model with clinical factors, was evaluated by comparison of C-index, net reclassification index, and integrated discrimination index. RESULTS: The mean age of recipients was 51.2±13.1 years (81.2% male), and the cumulative incidence of acute cellular rejection was 19.0% at 2 years. Patients with acute cellular rejection had significantly higher IMR values at 1 month than those without acute cellular rejection (23.1±8.6 versus 16.8±11.1, P=0.002). IMR was significantly associated with the risk of acute cellular rejection (per 5-U increase: adjusted hazard ratio, 1.18 [95% CI, 1.04-1.34], P=0.011) and the optimal cutoff value of IMR to predict acute cellular rejection was 15. Patients with IMR≥15 showed significantly higher risk of acute cellular rejection than those with IMR<15 (34.4% versus 3.8%; adjusted hazard ratio, 15.3 [95% CI 3.6-65.7], P<0.001). Addition of IMR to clinical variables showed significantly higher discriminant and reclassification ability for risk of acute cellular rejection (C-index 0.87 versus 0.74, P<0.001; net reclassification index 1.05, P<0.001; integrated discrimination index 0.20, P<0.001). CONCLUSIONS: Coronary microcirculatory dysfunction assessed by IMR measured early after heart transplantation showed significant association with the risk of acute cellular rejection. In addition to surveillance endomyocardial biopsy, early stratification using IMR could be a clinically useful tool to identify patients at higher risk of future acute cellular rejection after heart transplantation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02798731.

Predictor of atrial fibrillation recurrence in patients who underwent a tricuspid valve operation with modified Cox maze procedure.

BACKGROUND: Recurrence of any atrial arrhythmia after surgical ablation is known as a negative predictor of cardiovascular events and total mortality. However, there have been no focused studies for atrial fibrillation (AF) recurrence prediction in patients with significant tricuspid regurgitation (TR), and the risk-benefit estimation of surgical ablation in tricuspid valve (TV) surgery is not fully established. METHOD: We screened 385 patients who underwent a TV operation between 2001 and 2017. After excluding patients who did not undergo a maze operation, 158 patients were enrolled. Enrolled patients were divided by recurrence of AF. We analyzed the difference between the AF recurrence group and no AF recurrence group, and AF recurrence factors in terms of clinical risk factors and echocardiographic risk factors. The hazard ratio (HR) and 95% confidence intervals (CIs) were presented using a Cox proportional hazard model. RESULTS: Among 158 patients, AF recurred in 65 patients within 10 years. For AF prediction, age was most the important clinical factor and right atrium (RA) diameter was the most important echocardiographic parameters. In patients with a larger RA diameter over 49.2 mm, the prevalence of AF recurrence was higher (HR 4.322, 95% CI [2.185-8.549], log rank p value < .001). In clinical outcome, there was no significant difference between the AF recurrence group and the no recurrence group in terms of death, TR recurrence, heart failure, and stroke. However, the risk of permanent pacemaker (PPM) insertion was higher in the AF recurrence group (HR 10.240, 95% CI [1.257-83.480], log rank p value .007) compared to the no recurrence group. CONCLUSION: Age and RA enlargement are key predictors of AF recurrence after TV operation with the CM procedure in patients with significant TR.

Outcomes of extracorporeal membrane oxygenation in adults with active hematologic and nonhematologic malignancy.

Although the number of cancer patients admitted to the intensive care unit is increasing, the data on the use of extracorporeal membrane oxygenation in patients with malignancy are limited. We applied extracorporeal membrane oxygenation to carefully selected patients with active hematologic malignancy or nonhematologic malignancy who experienced respiratory or cardiac failure despite maximal conventional therapy. Patients with active malignancy who underwent extracorporeal membrane oxygenation in our institution between January 2012 and December 2016 were included in this study. The primary outcome of this study was defined as survival to hospital discharge. We also investigated the factors associated with survival to hospital discharge. There were 30 (30.6%) and 68 (69.4%) patients in the hematologic malignancy group and the nonhematologic malignancy group, respectively. Patients in the hematologic malignancy group were younger, more neutropenic, more hypotensive, had a lower Charlson Comorbidity Index, higher sequential organ failure assessment score, and lower platelet count than those in the nonhematologic malignancy group. Forty-six (46.9%) patients were successfully weaned off extracorporeal membrane oxygenation, and 30 (30.6%) patients survived until hospital discharge. Hospital survival rate and survival status 6 months after hospital discharge were significantly lower in patients with hematologic malignancy than in those with nonhematologic malignancy (13.3% vs. 38.2%, P = .026 and 3.3% vs. 26.5%, P = .017, respectively). Multivariate analysis identified an active hematologic malignancy, older age, acidosis, thrombocytopenia, high vasoactive-inotrope score, and respiratory failure as the risk factors for in-hospital death. Patients with hematologic malignancy requiring extracorporeal membrane oxygenation support had significantly lower rates of hospital survival and 6-month survival after discharge than patients with nonhematologic malignancy. Therefore, extracorporeal membrane oxygenation for treating cardiac or respiratory failure should only be considered in highly selected patients with hematologic malignancy.

Clinical Factors Associated with Renal Outcome After Heart Transplantation.

Cardiorenal syndrome (CRS) frequently occurs in end-stage heart failure patients waiting for heart transplantation (HT). Decision-making regarding simultaneous heart and kidney transplantation is an unresolved issue in these patients. We investigated clinical factors associated with renal outcome after HT. A total of 180 patients who received HT from 1996 to 2015 were included. Factors associated with early post-HT chronic kidney disease (CKD, estimated glomerular filtration rate [eGFR] < 60 mL/minute/1.73 m2 within 1 year post-HT), post-HT end-stage kidney disease (ESKD), and significant renal function improvement (%ΔeGFR > 15%) at 1 year post-HT were analyzed. Early post-HT CKD and post-HT ESKD developed in 61 (33.9%) and 8 (4.4%) of 180 patients, respectively. Old age was only independently associated with early post-HT CKD and preexisting CKD tended to be associated with early post-HT CKD. Old age and preexisting CKD were independently associated with post-HT ESKD. Low pre-HT eGFR and preoperative renal replacement therapy were not associated with early post-HT CKD or post-HT ESKD. Young age, low pre-HT eGFR, and high %ΔeGFR 1 month post-HT were independently associated with significant renal function improvement. Preoperative renal function, including preoperative RRT, was not associated with post-HT mortality. In conclusion, preexisting CKD may impact renal outcomes after HT, but preoperative severe renal dysfunction, even that severe enough to require RRT, may not be a contraindication for HT alone. Our data suggest the necessity of early HT in end-stage heart failure patients with CRS and the importance of careful management during the early postoperative period.

Optimal Timing of Venoarterial-Extracorporeal Membrane Oxygenation in Acute Myocardial Infarction Patients Suffering From Refractory Cardiogenic Shock.

BACKGROUND: Although there is an increase in the use of mechanical circulatory support devices to rescue patients with acute myocardial infarction (AMI) complicated by refractory cardiogenic shock (CS), the optimal timing of the application remains controversial. Therefore, this study aimed to compare the clinical outcomes between venoarterial-extracorporeal membrane oxygenation (VA-ECMO) insertion before and after coronary revascularization in AMI patients with refractory CS.Methods and Results:A total of 253 patients with AMI who underwent revascularization therapy with VA-ECMO were included. The study population was stratified into extracorporeal cardiopulmonary resuscitation (E-CPR) before revascularization (N=106, reference cohort) and refractory CS without E-CPR before revascularization (n=147, comparison cohort). Patients with refractory CS but without E-CPR before revascularization were further divided into VA-ECMO before revascularization (N=50) and VA-ECMO after revascularization (n=97). The primary endpoint was a composite of in-hospital mortality, left ventricular assist device implantation, and heart transplantation. The primary endpoint occurred in 60 patients (40.8%) of the comparison cohort and 51 patients (48.1%) of the reference cohort. Among the comparison cohort, the primary endpoint was significantly lower in VA-ECMO before revascularization than in VA-ECMO after revascularization (32.0% vs. 49.5%, OR 0.480, 95% CI 0.235-0.982, P=0.045). A similar trend was observed after a 1-year follow up. CONCLUSIONS: Early initiation of VA-ECMO before revascularization therapy might improve clinical outcomes in patients with AMI complicated by refractory CS.

Clinical Outcomes of Early Extubation Strategy in Patients Undergoing Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplantation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) might be considered a bridge therapy in patients who are expected to have short waiting times for heart transplantation. We investigated the clinical outcomes of patients who underwent VA-ECMO as a bridge to heart transplantation and whether the deployment of an early extubation ECMO strategy is beneficial. METHODS: Between November 2006 and December 2018, we studied 102 patients who received VA-ECMO as a bridge to heart transplantation. We classified these patients into an early extubation ECMO group (n = 24) and a deferred extubation ECMO group (n = 78) based on the length of the intubated period on VA-ECMO (≤ 48 hours or > 48 hours). The primary outcome was in-hospital mortality. RESULTS: The median duration of early extubation VA-ECMO was 10.0 (4.3-17.3) days. The most common cause for patients to be put on ECMO was dilated cardiomyopathy (65.7%) followed by ischemic cardiomyopathy (11.8%). In-hospital mortality rates for the deferred extubation and early extubation groups, respectively, were 24.4% and 8.3% (P = 0.147). During the study period, in the deferred extubation group, 60 (76.9%) underwent transplantation, while 22 (91.7%) underwent transplantation in the early extubation group. Delirium occurred in 83.3% and 33.3% of patients from the deferred extubation and early extubation groups (P < 0.001) and microbiologically confirmed infection was identified in 64.1% and 41.7% of patients from the two groups (P = 0.051), respectively. CONCLUSION: VA-ECMO as a bridge therapy seems to be feasible for deployment in patients with a short waiting time for heart transplantation. Deployment of the early extubation ECMO strategy was associated with reductions in delirium and infection in this population.

Target Temperature Management May Not Improve Clinical Outcomes of Extracorporeal Cardiopulmonary Resuscitation.

PURPOSE: Target temperature management (TTM) and extracorporeal cardiopulmonary resuscitation (ECPR) have been established as important interventions during cardiopulmonary arrest. However, the impact of combined TTM and ECPR on clinical outcomes has not been studied in detail. METHODS: We reviewed the records of 245 patients who received extracorporeal life support (ECLS) between January 2012 and June 2015. Exclusion criteria were as follows: Extracorporeal life support performed for reasons other than cardiac arrest, age less than 18 years, and death within 24 hours. A total of 101 patients were finally included in the study. Twenty-five patients underwent TTM, and 76 patients did not. RESULTS: The patients' mean age was 55 ± 16.7 years. The mean cardiac arrest time was 44.6 ± 33.5 minutes. There were 84 patients whose cardiac arrest was due to a cardiac cause (83.2%) and 79 patients with in-hospital cardiac arrest (78.2%). There was a significant difference in average body temperature during the first 24 hours following ECPR (33.4°C vs 35.6°C; P = .001). The overall favorable neurological outcome rate was 34% and hospital survival rate was 47%. There was no difference in favorable neurological outcomes and hospital survival between the TTM and non-TTM groups (P = .91 and .84, respectively). On multivariate analysis of neurological outcomes and hospital survival, TTM was not a significant prognostic factor. CONCLUSION: We did not observe any benefits of TTM in patients undergoing ECPR. Natural hypothermia or normothermia related to ECLS may explain this result. Further research is needed to understand the role of TTM in ECPR.

Off-Pump Coronary Artery Bypass Graft Versus Drug-Eluting Stent Implantation in Patients with Multivessel Disease Involving the Right Coronary Artery.

BACKGROUND: Whether percutaneous coronary intervention (PCI) is superior to coronary artery bypass grafting (CABG) for the right coronary territory is unknown. The aim of this study was to compare the outcomes and patency in the right coronary territory after CABG or PCI. METHODS: We studied 2,467 multivessel coronary artery disease patients from January 2001 to December 2011; 1,672 were off-pump CABG patients and 795 were PCI. The graft patency and the presence of major adverse cardiac and cerebrovascular events (MACCEs) including death, myocardial infarction, target vessel revascularization, and stroke were analyzed. RESULTS: After propensity score matching, cardiac-related survival was found to be significantly higher in the CABG group than in the PCI group (hazard ratio (HR) for the PCI group: 2.445, p = 0.006). The PCI group showed higher rates of myocardial infarction (HR: 2.571, p = 0.011) and target vessel revascularization (HR: 3.337, p < 0.001). In the right coronary territory, the right internal thoracic artery patency was not different in the PCI group compared with the CABG group (p = 0.248). In CABG group, low right coronary artery graft patency was associated with cardiac-related death (HR: 0.17, p = 0.003) and the occurrence of MACCEs (HR: 0.22, p < 0.001). CONCLUSION: CABG was superior to PCI in patients with multivessel disease. Low graft patency in the right coronary territory was associated with cardiac-related death and the occurrence of MACCEs.

Serial Changes of Transmitral and Transtricuspid Pressure Gradients After Simultaneous Mitral and Tricuspid Ring Annuloplasty.

BACKGROUND: Although flexible-ring annuloplasty is more inclined to increase the transmitral gradient over time, its effect on the tricuspid annulus is unknown. This study was conducted to evaluate serial changes in mean pressure gradient (mPG) across tricuspid and mitral valves after simultaneous dual implantation of flexible bands. METHODS: Seventy-one (71) patients (median age, 61.6 years; IQR: 50.8-69.0 years) underwent simultaneous mitral/tricuspid annuloplasties using St. Jude Tailor rings. Serial mPGs across mitral and tricuspid valves were evaluated at three postoperative time points: predischarge, 3 years, and 5 years. To gauge the effects and clinical outcomes of prophylactic intervention, patients were categorised as tricuspid regurgitation (TR)≥moderate or TR

Clinical Implication of Transaortic Mitral Pannus Removal During Repeat Cardiac Surgery for Patients With Mechanical Mitral Valve.

BACKGROUND: This study aimed to evaluate the safety and feasibility of transaortic mitral pannus removal (TMPR).Methods and Results:Between 2004 and 2016, 34 patients (median age, 57 years; 30 women) with rheumatic disease underwent pannus removal on the ventricular side of a mechanical mitral valve through the aortic valve during reoperation. The median time interval from the previous surgery was 14 years. TMPR was performed after removal of the mechanical aortic valve (n=21) or diseased native aortic valve (n=11). TMPR was performed in 2 patients through a normal aortic valve. The mitral transprosthetic mean pressure gradient (TMPG) was ≥5 mmHg in 11 patients, including 3 with prosthetic valve malfunction. Prophylactic TMPR was performed in 23 patients. There were no early deaths. Concomitant operations included 22 tricuspid valve surgeries (13 replacements, 15 repairs) and 32 aortic valve replacements (24 repeats, 8 primary). The mean gradient in patients who had mitral TMPG ≥5 mmHg was significantly decreased from 6.46±1.1 to 4.37±1.17 mmHg at discharge (P<0.001). No mechanical valve malfunction was apparent on last echocardiography. CONCLUSIONS: TMPR is a safe and effective procedure for patients with malfunction or stenosis of a mechanical mitral valve and may be considered an alternative approach in patients with pannus overgrowth in such valves.

Clinical Outcomes of Repeat Aortic Valve Replacement for Subaortic Pannus in Mechanical Aortic Valve.

BACKGROUND: This study aimed to evaluate the early and late clinical outcomes after repeat aortic valve replacement (AVR) for subaortic pannus in patients with mechanical valves. Methods and Results: Between 2001 and 2017, 51 patients (median age, 59 years; 42 women) with prosthetic aortic stenosis (AS) caused by pannus ingrowth underwent repeat AVR because of acute malfunction of monoleaflet valve (3 patients), severe prosthetic AS (30 patients), and moderate prosthetic AS at the time of tricuspid or mitral valve surgery (18 patients). The median follow-up duration was 100 (interquartile range, 64-138) months. Double valve replacement was performed in 45 (88%) patients. Median time interval from previous operation was 161 (interquartile range, 121-194) months. The explanted mechanical AV was monoleaflet and bileaflet in 16 (31%) and 34 (67%) patients, respectively. Concomitant procedures included 16 mitral valve replacements (14 repeat) and 36 tricuspid valve surgeries (15 replacements, 21 repairs). No hospital deaths or cases of heart block occurred. Overall survival and event-free survival rates at 10 years were 88% and 51%, respectively. Late complications included recurrent prosthetic AS (4 patients), new paravalvular leakage of the mitral valve (5 patients), and severe tricuspid regurgitation (2 patients). CONCLUSIONS: Although repeat AVR for subaortic pannus had acceptable early and late survival, recurrent prosthetic AS was frequently observed during late follow-up.

Prognostic value of computed tomography score in patients after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: We evaluated whether Alberta Stroke Program Early Computed Tomography Score (ASPECTS) with some modifications could be used to predict neurological outcomes in patients after extracorporeal cardiopulmonary resuscitation (ECPR). METHODS: This was a retrospective, multicenter, observational study of adult unconscious patients who were evaluated by brain computed tomography (CT) within 48 hours after ECPR between May 2010 and December 2016. ASPECTS, bilateral ASPECTS (ASPECTS-b), and modified ASPECTS (mASPECTS) were assessed by ROC curves to predict neurological outcomes. The primary outcome was neurological status upon hospital discharge assessed with the Cerebral Performance Categories (CPC) scale. RESULTS: Among 58 unconscious patients, survival to discharge was identified in 25 (43.1%) patients. Of these 25 survivors, 19 (32.8%) had good neurological outcomes (CPC score of 1 or 2). Interrater reliability of CT scores was excellent. Intraclass correlation coefficients of ASPECTS, ASPECTS-b, and mASPECTS were 0.918 (95% CI, 0.865-0.950), 0.918 (95% CI, 0.866-0.951), and 0.915 (95% CI, 0.860-0.949), respectively. The predictive performance of mASPECTS for poor neurological outcome was better than that of ASPECTS or ASPECTS-b (C-statistic for mASPECTS vs. ASPECTS, 0.922 vs. 0.812, p = 0.004; mASPECTS vs. ASPECTS-b, 0.922 vs. 0.818, p = 0.003). A cutoff of 25 for poor neurological outcome had a sensitivity of 84.6% (95% CI, 69.5-94.1%) and a specificity of 89.5% (95% CI, 66.9-98.7%) in mASPECTS. CONCLUSIONS: mASPECTS might be useful for predicting neurological outcomes in patients after ECPR.

Surgical outcomes of mitral valve replacement with concomitant mitral annular reconstruction.

BACKGROUND AND AIM OF THE STUDY: We evaluated the early and long-term outcomes of mitral annular reconstruction (MAR) with pericardium during mitral valve replacement (MVR), and analyzed the risk factors associated with post-operative mortality. METHODS: Between May 1997 and April 2013, 78 consecutive patients underwent MVR with MAR. The indications for MAR were treatment for annular infection in native valve endocarditis (n = 23, 29.5%) or prosthetic valve endocarditis (n = 26, 33.3%), reinforcement of damaged annulus resulting from a previous operation (n = 17, 21.8%), complete excision of extensive calcification (n = 9, 11.5%), and left ventricular or left atrial rupture (n = 3, 3.8%). Patients were classified into infective endocarditis (n = 49) and non-endocarditis groups (n = 29). The mean follow-up period was 59.4 ± 47.3 months. RESULTS: There were two operative deaths and 11 cases of late mortality in the endocarditis group and five cases in the non-endocarditis group. Late prosthetic valve endocarditis occurred in four patients. The overall survival rate at 1 and 10 years was 94.8% and 65.1%, respectively. There was no statistical difference in the overall survival, freedom from reoperation, and freedom from endocarditis rates between the groups (P = 0.565, P = 0.635, and P = 0.449, respectively). Univariable and multivariable analyses revealed that pre-operative left ventricular dysfunction (ejection fraction <40%) was an independent predictor of overall mortality. CONCLUSIONS: The early and long-term results of MAR with pericardium during MVR are acceptable in both endocarditis and non-endocarditis patients.

Perioperative Outcomes of Repeated Open Surgery on the Thoracic Aorta.

BACKGROUND: Repeated thoracic aorta repair is increasingly common. With the increase in hybrid procedures, determination of the best treatment strategy requires evaluation of the clinical outcomes of classic open surgery. METHODS: We retrospectively reviewed 119 patients (84 men and 35 women, aged 51.0 ± 16.7 years) with a history of open repair involving the thoracic aorta above the diaphragm. The patients underwent an average of 1.3 ± 0.8 surgeries (range: 1-8) on the thoracic aorta before the final operation. Clinical outcomes were evaluated on the basis of the need for emergency surgery, indications for surgery, pathologic causes, and other operative variables. RESULTS: Hospital mortality was 6.7% (n = 8). Postoperative bleeding occurred in 16% (n = 19). On multivariable analysis, emergency surgery (odds ratio [OR], 19.005; P = .003; 95% confidence interval [CI], 2.710-133.305) and cardiopulmonary bypass (CPB) time (OR, 1.562 per 30 minutes; P = .007; 95% CI, 1.126-2.165) were predictors of hospital death. Emergency surgery (OR, 4.105; P = .029; 95% CI, 1.157-14.567) and CPB time (OR, 1.189 per 30 minutes; P = .035; 95% CI, 1.012-1.396) were also associated with postoperative bleeding, in addition to surgery for an infectious cause (OR, 10.824; P = .010; 95% CI, 1.755-66.770). Estimated survival at 1, 5, and 7 years was 86.6%, 80.5%, and 78.2%, respectively. CONCLUSION: Despite the variety of preoperative conditions and operations performed, repeated open surgery for thoracic aorta repair can be performed with acceptable early and late outcomes.

Tricuspid Valve Replacement vs. Repair in Severe Tricuspid Regurgitation.

BACKGROUND: The aim of this study was to compare early and late outcomes of tricuspid valve replacement (TVR) and tricuspid valve repair (TVr) for severe tricuspid regurgitation (TR).Methods and Results:From 1994 to 2012, 360 patients (mean age, 58±13 years) with severe TR underwent TVR (n=97, 27%) or TVr (n=263, 73%). Among them, 282 patients (78%) had initial rheumatic etiology, and 307 patients (85%) had preoperative atrial fibrillation. The TVR group had higher total bilirubin, higher baseline central venous pressure, and higher incidence of previous cardiac operation. There was no difference in early mortality (TVR:TVr, 3.1%:3.4%, P=0.877). Ten-year overall survival (TVR:TVr, 72%:70%, P=0.532) and 10-year freedom from cardiac death (TVR:TVr, 76%:77%, P=0.715) were not significantly different between groups. After applying stabilized inverse probability of treatment weighting methods, there were still no significant differences in early mortality (P=0.293), overall survival (P=0.649) or freedom from cardiac death (P=0.870). Higher NYHA functional class, total bilirubin (>2 mg/dL), initial central venous pressure, and cardiopulmonary bypass time were independent predictors of early mortality. Older age, LV dysfunction (EF <40%), and hemoglobin <10 g/dL were independent predictors of late cardiac mortality. CONCLUSIONS: Compared with TVr, TVR had acceptable early and late outcomes in patients with severe TR. TVR can be considered as a valid option with acceptable clinical outcomes in patients who are not suitable candidates for TVr.

The association of findings on brain computed tomography with neurologic outcomes following extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Limited data are available on imaging predictors of neurological outcomes after extracorporeal cardiopulmonary resuscitation (ECPR). We investigated the association of initial brain computed tomography (CT) findings with neurological outcomes following ECPR. METHODS: Between February 2005 and December 2015, a total of 42 patients who underwent brain CT scans within 48 h after ECPR were analyzed. Loss of the boundary between gray matter and white matter (LOB) or cortical sulcal effacement (SE), gray-to-white matter ratio (GWR), and optic nerve sheath diameter (ONSD) were measured on initial brain CT. The primary outcome was the Cerebral Performance Categories (CPC) scale at discharge. RESULTS: Of the 42 adult ECPR patients, 23 (54.8%) patients survived to discharge and 19 (45.2%) patients had good neurological outcomes (CPC 1 and 2). The area under the curve (AUC) of GWR in the basal ganglia (GWR-BG) was 0.792 (95% confidence interval (CI), 0.639-0.901, p = 0.001). ONSD (AUC 0.745; 95% CI, 0.587 - 0.867, p = 0.007) was 5.57 (interquartile range (IQR) 5.14 - 5.98) mm in the good neurological outcome group versus 6.07 (IQR 5.71 - 6.64) mm in the poor outcome group. LOB or SE were more often detected in the poor neurological outcome group (AUC 0.817; 95% CI, 0.682-0.952, p <0.001). The predictive performance of poor neurological outcomes of a composite of GWR-BG, ONSD, and LOB/SE was significantly improved (AUC 0.904; 95% CI, 0.773-0.973) compared to when each brain CT marker was considered separately (GWR-BG, p = 0.048; ONSD, p = 0.026; LOB/SE, p = 0.028). CONCLUSIONS: GWR, ONSD, and LOB/SE on initial brain CT scans are associated with neurological prognosis in patients who underwent ECPR. The new risk prediction model, which uses a composite of GWR, ONCD, and LOB/SE, could provide better information on neurologic outcomes in patients underwent ECPR.

Favorable Outcomes of Open Surgical Repair for Blunt Aortic Injury in the Era of Endovascular Repair.

Background Long-term outcomes of open surgical repair with distal aortic perfusion for blunt aortic injury (BAI) remain undefined in this era of preferential thoracic endovascular aortic repair (TEVAR). Methods We retrospectively reviewed data from 31 consecutive patients (23 males; mean age, 46 ± 16 years) who underwent open surgical repair with distal aortic perfusion for acute BAI between 1998 and 2012 at our center and were followed up for 83 ± 47 months. Results In the 31 patients studied, BAI was most commonly secondary to traffic accidents (87%), with median accident-to-surgery time of 1 day. It was most commonly (90%) located at the isthmus. All patients had other injuries (injury severity score, 25 ± 6), 68% of which required surgery. The aorta was approached by left (84%) or bilateral (3%) thoracotomy, or median sternotomy (13%). During aortic cross-clamping (73 ± 47 minutes), distal aortic perfusion was maintained in all patients by left heart or cardiopulmonary bypass (extracorporeal circulation time, 93 ± 63 minutes). Circulatory arrest was required in 19% of patients. There was no in-hospital mortality or paraplegia. The estimated 5- and 10-year survival rates were 92 ± 6% and 80 ± 12%, respectively. One patient underwent reoperation for aortoesophageal fistula at 75 months postoperatively. Conclusion Open repair with distal aortic perfusion for BAI yielded favorable early and late outcomes, and is thus a viable option even in the era of TEVAR.

Percutaneous removal using Perclose ProGlide closure devices versus surgical removal for weaning after percutaneous cannulation for venoarterial extracorporeal membrane oxygenation.

OBJECTIVE: The removal of arterial cannulas using a Perclose device (Abbott Vascular, Clonmel, Tipperary, Ireland) has not been reported in patients undergoing venoarterial extracorporeal membrane oxygenation (ECMO). We investigated the procedural outcomes and complications of percutaneous device closure vs surgical repair for hemostatic control of the arterial access site in weaning from venoarterial ECMO. METHODS: Between September 2012 and December 2014, 115 patients with ECMO weaned by percutaneous or surgical access were enrolled. The percutaneous technique used two ProGlide devices (Abbott Vascular) by direct puncture of an arterial cannula at the time of weaning off ECMO. The primary outcomes were composite complications of open repair at the insertion site, limb ischemia after removal of the arterial cannula, removal site infection, pseudoaneurysm, distal part embolization, and 10 minutes or more manual compression at the weaning site. RESULTS: The percutaneous technique was performed on 56 patients, and the surgical exposure technique was performed on 59. Technical success was not significantly different between the percutaneous and surgical groups (85.7% vs 86.4%; P = 1.0) although the procedure duration (17.15 ± 9.38 minutes vs 64.33 ± 31.67 minutes; P < .001) was shorter in the percutaneous access group. A composite of procedure-related complications and length of stay in the intensive care unit after weaning was not significantly different between groups (17.9% vs 28.8%; P = .19 and 16.82 ± 38.53 days vs 19.69 ± 21.40 days; P = .62). CONCLUSIONS: Percutaneous access using two Perclose ProGlide devices was a feasible and safe strategy for weaning from ECMO.