Efficacy of Preemptive Embolization of Sac Branches During Endovascular Aneurysm Repair Using N-butyl-2-cyanoacrylate.

OBJECTIVE: A type 2 endoleak (T2EL) is the most frequently occurring endoleak type after endovascular aneurysm repair (EVAR). Residual T2ELs may cause aneurysm rupture; however, the management of a T2EL remains controversial. This study evaluated sac branch preemptive embolization using N-butyl-2-cyanoacrylate, aiming to prevent T2ELs and sac shrinkage. METHODS: Twelve consecutive patients underwent elective preemptive embolization during EVAR at our hospital between August 2018 to March 2019. Their demographic information, operative details, and sac diameters were examined at 6 months after EVAR. RESULTS: No procedural complications were observed. There were no in-hospital deaths among the 12 patients. Sac shrinkage was observed in this cohort (53.8-52.1 mm, p = 0.01). A total of 33 lumbar arteries were occluded with this procedure, and 2 patients had residual T2ELs at 6 months. CONCLUSIONS: A T2EL in preemptive sac branch embolization during EVAR has advantages in terms of safety and reduction. Although no clear evidence is available for the management of T2ELs, this study proposes a new standard to prevent it and improve the long-term outcomes after EVAR. However, embolization remains imperfect and further research is necessary.

Feasibility and Outcome of Transjugular Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement.

Background: There are limited data on the impact of intracardiac echocardiography (ICE)-guided transcatheter aortic valve replacement (TAVR) on the new permanent pacemaker implantation (PPMI) rate. Objectives: This study investigated the feasibility and outcome of transjugular ICE (TJ-ICE) -guided TAVR, by visualizing the relationship between the membranous septum (MS) and the transcatheter aortic valve (TAV). Methods: Among patients with severe aortic stenosis who underwent TAVR between February 2017 and June 2020, this study enrolled a total of 163 patients with TJ-ICE-guided TAVR. MS length was measured by ICE. The primary endpoint of this study was the incidence of new PPMI at 30 days. Results: The mean age of the patients in this study was 84.9 ± 4.6 years, and 71.2% of the patients were female. Device success was 96.3% with TJ-ICE guidance. A TJ-ICE-related complication occurred in 1 case (0.6%). The median length of the MS was 5.8 mm (IQR: 5.0-6.9 mm). Excellent intraobserver (intraclass correlation coefficient [ICC]: 0.94; 95% CI:0.79-0.98; P < 0.001) and interobserver (ICC: 0.93; 95% CI: -0.05 to 0.98; P < 0.001) agreements were shown. The new PPMI rate was 6.7% at 30 days without a significant difference between balloon-expandable valves and self-expandable valves (3.4% vs 8.7%; P = 0.226). Patients with a TAV implantation depth less than MS length had a significantly lower incidence of new PPMI compared with patients with a TAV implantation depth greater than MS length (2.1% vs 13.4%; P = 0.005), regardless of baseline right bundle branch block presence (6.7% vs 66.7%; P = 0.004) or absence (1.2% vs 8.2%; P = 0.041). Conclusions: TJ-ICE-guided TAVR demonstrated remarkable feasibility and safety. The TJ-ICE-guided final TAV position had a significant impact on the new PPMI rate. (Tokai Valve Registry; UMIN000036671).

AATS 2023: Left ventricular restoration with scar exclusion in the surgical treatment for ischemic heart failure.

OBJECTIVE: Post-infarction myocardial scar as detected by cardiac magnetic resonance (CMR) is associated with adverse left ventricular (LV) remodeling and negatively affects the prognosis. We sought to analyze the impact of left ventricular restoration (LVR) with asynergic scar exclusion on long-term outcomes for patients with ischemic heart failure (IHF). METHODS: From January 2005, 134 consecutive patients with IHF underwent scar-exclusive LVR. Among the 131 survivors, 108 patients had paired late gadolinium enhancement (LGE)-CMR preoperatively and one year after, and represent the study population. Patients were divided into two groups according to whether their post-LVR residual percentage of scarred LV perimeter was <35% (%Scar <35; n = 55) or more (%Scar ≥35; n = 53). We compared the two groups, by looking at LGE-CMR outcomes, and at long-term survival and cardiac event (hospitalization for cardiac causes)-free survival. RESULTS: Postoperative LV end-systolic volume index decreased significantly and ejection fraction increased with significant increase in stroke volume index (P < 0.05 for both). LV diastolic function of the left atrial volume index was significantly improved in patients with residual %Scar <35 than in those with %Scar ≥35 (P interaction = 0.005). Median survival in patients with residual %Scar <35 and ≥ 35 were 8.3 (4.5-12.2) years and 6.8 (1.8-11.8) years respectively (P = 0.106). Median cardiac event-free survival in patients with %Scar <35 and ≥ 35 were 8.0 (3.9-12.1) years and 4.8 (0.8-8.8) years respectively (P < 0.001). CONCLUSIONS: Scar-exclusive LVR yielded sustainable improvement in LV function and favorable long-term survival regardless of the extent of residual scar. The LVR should be performed to attain scar exclusion in the surgical treatment for IHF, which in turn might protectively affect LV diastolic function and cardiac event-free survival.

Successful Medical Treatment for Aortoesophageal Fistula after Thoracic Endovascular Aortic Repair.

Aortoesophageal fistula is a fatal disease that requires surgical treatment. Due to the patient's wishes, we chose medical treatment for aortoesophageal fistula after thoracic endovascular aortic repair for a pseudoaneurysm in the distal anastomotic site after total aortic arch replacement. Satisfactory early and long-term outcomes were obtained with complete fasting and appropriate antibiotics.

Sustained Myocarditis following Messenger RNA Vaccination against Coronavirus Disease 2019: Relation to Neutralizing Antibody and Amelioration by Low-Dose Booster Vaccination.

We recently reported that sub-acute myocarditis occurred following the initial two doses of messenger RNA-based vaccination against coronavirus disease 2019 (0.3 mL Comirnaty®) in elderly Japanese patients with cardiac dysfunction. The present retrospective study of 76 patients revealed that myocarditis following the initial doses persisted for 12 months, was associated with low levels of neutralizing antibodies, and was ameliorated by reducing the third vaccine dose. Low neutralizing antibody levels (<220 U/mL) after the initial doses were an independent predictor of persistent clinical events, defined as death or marked changes in brain natriuretic peptide levels. When the third dose was reduced (0.1 mL), changes in brain natriuretic peptide levels were significantly smaller (p = 0.02, n = 25), no deaths occurred due to heart failure, and neutralizing antibody levels increased 41-fold (p < 0.001) compared with the initial doses. Reduced booster doses could facilitate the worldwide distribution of messenger RNA vaccines.

Nitric Oxide Inhalation and V-V ECMO for Severe Respiratory Failure after Acute Type A Aortic Dissection Surgery.

A 65-year-old man was admitted to our hospital with acute type B aortic dissection that extended into both common iliac arteries with an occluded right common iliac artery and large bullae in bilateral upper lung fields. Femoro-femoral arterial bypass surgery with an artificial blood vessel was performed. Two days postoperatively, acute type B aortic dissection progressed to acute type A aortic dissection. Emergency total arch graft replacement (TAR) was performed through a median sternotomy on the same day. Immediately following TAR, the patient experienced hypoxemia. Acute respiratory distress syndrome (ARDS) was diagnosed following TAR for acute aortic dissection with pneumonia. Nitric oxide inhalation (NOI) therapy was commenced at 20 ppm from the fourth day post-surgery. However, 6 d following TAR, he developed bilateral pneumothorax due to ruptured bullae requiring chest tube management and thoracoscopic left upper lobe bullectomy. Eight days following TAR, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initiated and NOI therapy was completed. V-V ECMO was withdrawn 18 d after TAR. Postoperatively, after 2 years 3 months, the patient remains ambulatory without assistance, walking to the outpatient clinic.

Optimizing self-expandable transcatheter heart valve sizing in patients with small sinus of Valsalva.

OBJECTIVES: To evaluate the feasibility and efficacy of transcatheter aortic valve replacement (TAVR) in patients with small sinus of Valsalva (SOV). BACKGROUND: Patients with small SOV are considered unfavorable for TAVR since it carries risk of coronary obstruction after valve implantation. Therefore, these patients with small SOV were excluded from previous clinical trials. METHODS: Between February 2017 and February 2019, a total of 139 consecutive patients with severe aortic stenosis (AS) undergoing TAVR were prospectively enrolled in the Tokai Valve Registry. Patients with small SOV who were treated with smaller size of self-expandable transcatheter heart valve (THV) than expected by perimeter-based sizing were included in this study. Eleven patients (7.9%) were included. RESULTS: Mean age was 86.5 ± 3.8 years and median STS Score was 8.5% (interquartile range: 6.3-12.3%). Device success was accomplished in all patients and no coronary obstruction was observed. No moderate/severe paravalvular leakage, new onset conduction disturbance, and new permanent pacemaker implantation were noted. At 30-day follow-up, mean aortic valve gradient was 6.9 ± 1.7 mmHg and mean indexed aortic valve area was 0.95 ± 0.16 cm2 /m2 . Prosthetic valve performance was stable at 12-month follow-up. No severe prosthesis patient mismatch was documented at any time point. No in-hospital, 30-day, and 12-month mortality were observed. The median follow-up was 711 days (IQR: 547-803 days), and no patient was lost to follow-up. CONCLUSIONS: Our preliminary experience suggests favorable safety and efficacy of TAVR utilizing self-expandable THV with intentional down-sizing in patients with severe AS and small SOV in a mid-term follow-up.

Non-heart transplant surgical approaches with mitral valve operation and surgical ventricular reconstruction for non-ischaemic dilated cardiomyopathy: a Japanese multicenter study.

OBJECTIVES: There is uncertainty over the efficacy of additional surgical ventricular reconstruction (SVR) associated with mitral valve operation for non-ischaemic dilated cardiomyopathy (DCM). This study aims to assess mid-term outcomes of these non-heart transplant surgical approaches for DCM. METHODS: We reviewed retrospectively 106 patients (median age 64, 44 females) who underwent isolated mitral annular plasty (MAP; n = 34), mitral valve replacement (MVR; n = 29), and SVR associated with MAP (SVR + MAP; n = 43) for DCM, in 11 Japanese hospitals. We analysed mid-term outcomes, specifically freedom from cardiac death and cardiac event. RESULTS: Hospital deaths occurred in 16 patients (15.1%) and cardiac deaths in 36 patients (34.0%) during the study period of 4.4 ± 3.5 years. Freedom from cardiac death at 7 years in patients undergoing MAP, MVR, and SVR + MAP were, respectively, 79.1%, 82.6%, and 29.5% (P < 0.0001). Freedom from cardiac event at 7 years in patients undergoing MAP, MVR, and SVR + MAP were, respectively, 42.8%, 59.9%, 22.6% (P = 0.0004). In the multivariable analyses, preoperative tricuspid regurgitation (TR) grade was the only risk factor for both cardiac death and event, whereas MVR for DCM emerged as a protective factor for cardiac event. CONCLUSIONS: This study could not show any benefit of additional SVR, by means of volume reduction, to MAP, because the baseline characteristics were different even after the stratification of DCM grade. MVR can be performed with favorable mid-term outcomes even in patients with advanced DCM, while patients undergoing MAP with/without SVR had more frequent MR recurrence or cardiac events. Interestingly, the right ventricular feature is a predictor of both cardiac death and events, with the TR grade being a predictor of poor mid-term outcomes.

Echocardiography-guided aortic cannulation by the Seldinger technique for type A dissection with cerebral malperfusion.

OBJECTIVE: The purpose of this study was to assess the efficacy of echocardiography-guided ascending aortic central cannulation using the Seldinger technique during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion. METHODS: Between April 2007 and December 2017, 208 patients with type A acute aortic dissection underwent echocardiography-guided ascending aortic central cannulation using the Seldinger technique. We analyzed 16 of these patients (7.7%; median age, 63 years; 8 men) with stroke due to cerebral malperfusion, including 10 in a comatose state (Glasgow Coma Scale ≤8) and 6 with hemiplegia (manual muscle test ≤1) on hospital arrival. The Modified Rankin Scale was used to evaluate activities of daily living. RESULTS: The median time from onset of symptoms to establishment of cardiopulmonary bypass was 327 (176-561) minutes. The median time from the start of surgery to establishment of cardiopulmonary bypass was 34 (30-44) minutes. The mortality rate was 6.3% (1/16). In patients with preoperative coma, the Glasgow Coma Scale improved significantly after surgery from 4.5 to 15 at 30 days (P < .001). In patients with preoperative hemiplegia, 4 showed improved motor function on the manual muscle test score at 90 days. In all patients, Modified Rankin Scale scores improved significantly from 5.0 preoperatively to 1.0 after follow-up (P < .001). CONCLUSIONS: Echocardiography-guided ascending aortic central cannulation using the Seldinger technique has potential as a rapid and reliable perfusion route during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion.

Estimating postoperative left ventricular volume: Identification of responders to surgical ventricular reconstruction.

OBJECTIVES: The postoperative left ventricular end-systolic volume index and ejection fraction are benchmarks of surgical ventricular reconstruction but remain unpredictable. This study aimed to identify who could be associated with a higher long-term survival by adding surgical ventricular reconstruction to coronary artery bypass grafting than coronary artery bypass grafting alone (responders to surgical ventricular reconstruction). METHODS: The subjects were 293 patients (median age, 63 years; 255 men) who underwent coronary artery bypass grafting for ischemic heart disease with left ventricular dysfunction in 16 cardiovascular centers in Japan. The relationships among surgical ventricular reconstruction, postoperative end-systolic volume index, ejection fraction, and survival were analyzed to identify responders to surgical ventricular reconstruction. RESULTS: Surgical ventricular reconstruction was performed in 165 patients (56%). The end-systolic volume index and ejection fraction significantly improved (end-systolic volume index, 91 to 64 mL/m2; ejection fraction, 28% to 35%) for all patients. The postoperative end-systolic volume index and ejection fraction were estimated, and surgical ventricular reconstruction was found to be significantly associated with both end-systolic volume index (14.5 mL/m2 reduction, P < .001) and ejection fraction (3.1% increase, P = .003). During the median follow-up of 6.8 years, 69 patients (24%) died. Only the postoperative ejection fraction was significantly associated with survival (hazard ratio, 0.925; 95% confidence interval, 0.885-0.968), although this effect was limited to those with postoperative end-systolic volume index of 40 to 80 mL/m2 in the subgroup analysis (hazard ratio, 0.932; 95% confidence interval, 0.894-0.973). CONCLUSIONS: Adding surgical ventricular reconstruction to coronary artery bypass grafting could reduce the mortality risk by increasing ejection fraction for those with a postoperative end-systolic volume index within a specific range. The postoperative end-systolic volume index could demarcate responders to surgical ventricular reconstruction, and its estimation can help in surgical decision making.

Distal aortic arch aneurysm in an adult case of PHACE syndrome.

A rare case of adult PHACE syndrome with a distal aortic arch aneurysm was treated surgically. The patient had several anomalies including uneven cerebral blood flow, a small left common carotid artery and a narrowed transverse aorta. Under deep hypothermic circulatory arrest, aortic replacement with reconstruction of the left subclavian artery was performed uneventfully. Cystic degeneration of the tunica media was observed in the aneurysm wall.

The proliferative potential of human cardiac stem cells was unaffected after a long-term cryopreservation of tissue blocks.

BACKGROUND: Human c-kit-positive cardiac stem cells (CSCs) have been used to treat patients suffering from ischemic cardiomyopathy. This study aimed to investigate whether a long-term storage of cardiac tissues would influence the growth potential of the subsequently isolated CSCs. METHODS: A total of 34 fresh samples were obtained from various cardiac regions [right atrium (RA), left atrium (LA), and/or left ventricle (LV)] of 21 patients. From 12 of these patients, 18 samples kept frozen for ~2 years were employed to prepare and characterize the CSCs. After confirming the specificity of the cell sorting by c-kit immunolabeling, the growth rate (number of doublings per day), BrdU positivity, and colony forming unit (CFU) were measured in each CSC population; the values were compared among distinct cardiac regions as well as between fresh and frozen tissues from which CSCs were derived. RESULTS: Among independent measurements indicating growth potential, the growth rate and BrdU positivity remarkably correlated in freshly prepared CSCs. The cells obtained from every examined region displayed a high proliferative capacity with the growth rate of 0.48±0.19 and the BrdU positivity of 15.0%±7.6%. The right atrial CSCs tended to show a greater growth than those in the other two areas. Similarly, the CSCs were isolated from tissue blocks, cryopreserved for ~2 years, and compared with CSCs derived from the fresh specimens of the same patients. Importantly, we were able to obtain and culture CSCs from every frozen material, and their proliferative potential, represented by the growth rate of 0.47±0.22 and the BrdU positivity of 13.7%±7.9%, was not inferior to that of the freshly prepared cells. CONCLUSIONS: The long-term cryopreservation of cardiac tissues did not affect the growth potential of the derivative CSCs. Our findings should expand the therapeutic applications of these cells over a longer time span.

The SYNTAX score is correlated with long-term outcomes of coronary artery bypass grafting for complex coronary artery lesions.

OBJECTIVES: We analysed retrospectively the long-term outcomes of conventional coronary artery bypass grafting (CABG) as employed routinely for complex coronary lesions by observing patients with low (0-22), intermediate (23-32) and high (≥33) SYNTAX scores. The purpose of this study was to evaluate the correlation between the SYNTAX score and long-term major adverse cardiac and cerebrovascular events (MACCEs) including all-cause death, stroke, myocardial infarction (MI) and repeat revascularization after CABG. METHODS: The study enrolled 396 consecutive patients with stable and untreated left main and/or three-vessel disease, who had been referred to our heart team from 2000 through 2009. They all routinely underwent conventional CABG. The three groups (low score; n = 159, intermediate score; n = 150, high score; n = 87) were compared, looking at the primary endpoint of MACCE and its components. We also analysed the effects of diverse variables on long-term MACCEs after the operation. RESULTS: The cumulative 10-year MACCE rates in patients with low, intermediate and high SYNTAX score were 25.3, 35.8 and 48.1%, respectively. The Kaplan-Meier cumulative event curves showed a significantly higher MACCE rate after CABG in patients with a higher SYNTAX score than in those with a lower score (log-rank P = 0.0012). This was mainly because of a significantly increased rate of repeat revascularization in the higher SYNTAX score group (log-rank P = 0.0032). The cumulative rate of repeat revascularization at 10 years in patients having low, intermediate and high SYNTAX score were, respectively, 4.6, 15.7 and 16.8%. The cumulative rates of the combined outcomes of death/stroke/MI at 10 years did not show statistical differences between the three groups (22.3% with low, 25.0% with intermediate and 38.4% with high score, log-rank P = 0.063). In the multivariable analysis, the SYNTAX score [hazard ratio (HR) 1.03, P = 0.0043] and logistic EuroSCORE II (HR 1.34, P = 0.0012) were found to be significant predictors of long-term MACCEs. CONCLUSIONS: The SYNTAX score is correlated with long-term outcomes, in terms of MACCEs, after conventional CABG for complex coronary lesions and is prognostic of long-term outcomes of CABG for patients with complex lesions.

Long-term outcomes and risk analyses of coronary bypass for left main disease.

BACKGROUND: We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease. METHODS: From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation. RESULTS: The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003). CONCLUSIONS: With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.

Non-heart transplant surgical approaches with left ventricular restoration and mitral valve operation for advanced ischaemic cardiomyopathy.

OBJECTIVES: The aim of this study was to assess long-term outcomes of non-heart transplant surgical approaches to advanced ischaemic cardiomyopathy (ICM), including left ventricular restoration (LVR) and mitral valve operation. METHODS: Since September 2002, 102 consecutive patients (mean age 65, 18 females) with advanced ICM [ejection fraction (EF) <40%, left ventricular end-systolic volume index (LVESVI) > 60 ml/m(2)] were treated using non-heart transplant procedures. A total of 84 patients with asynergy of large scar exceeding 35% of left ventricular (LV) perimeter underwent LVR, and 30 patients with greater than or equal to moderate mitral regurgitation (MR) underwent mitral valve operation such as annuloplasty (n = 23) and valve replacement (n = 7). Patients were divided into four groups according to their interagency registry for mechanically assisted circulatory support (INTERMACS) profiles: Profile 1-2 (the highest levels of clinical compromise; n = 9), Profile 3-4 (n = 40), Profile 5-6 (n = 32) and Profile ≥ 7 (n = 21). We compared the four groups, looking at survival, major adverse cardiac and cerebrovascular event (MACCE), New York Heart Association (NYHA) status, LV volume and function. RESULTS: The overall 8-year survival including 3 hospital deaths (2.9%) was 64.3% without sudden death due to arrhythmia. Ninety-nine survivors showed significant improvement in the mean NYHA status, from 2.9 to 1.4, and the mean EF (33.2-41.7%) (P < 0.0001). The mean LVESVI was significantly reduced from 104.1 to 61.4 ml/m(2) (41% volume reduction) (P < 0.0001). Seven-year survival in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 50.0, 57.2, 60.3 and 95.2%, respectively (P = 0.13). Freedom from MACCE at 5 years in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 29.6, 47.0, 67.2 and 95.2%, respectively (P = 0.0067). The improvements in NYHA status were significantly greater in patients with higher levels of clinical compromise (P < 0.0001), although, there was no significant difference in LV volume reduction and functional improvement among the four groups. Patients with Profile ≥ 7 had significantly better survival at 7 years (hazard ratio (HR): 0.11, P = 0.046) and freedom from MACCE at 5 years (HR: 0.053, P = 0.0066) compared with patients with Profiles 1-2. CONCLUSIONS: Our non-heart transplant surgical approaches using LVR and mitral valve operation for advanced ICM yielded excellent long-term outcomes in terms of survival and NYHA status, even in patients who are potential candidates for heart transplantation or LV assist devices; and are encouraging in a very particular situation where heart transplantation is limited due to organ storage.

Relationship between locations of rib defects and loss of respiratory function - a biomechanical study.

OBJECTIVE: The present study elucidates the relationship between the locations of rib defects and loss of respiratory function. METHODS: Ten sets of three-dimensional finite element models were produced from computed tomography data of 10 persons and categorized as normal type models. These models were modified by removing part of the ribs, and the resultant models were categorized as defect type models. Varying the location of the defects, six types of defect model were produced from each of the 10 normal models; the defects were made on the anterior-superior, anterior-inferior, lateral-superior, lateral-inferior, posterior-superior, and posterior-inferior regions of the thorax. To simulate respiration, contracture forces were applied to nonlinear springs modeling respiratory muscles for each of the normal and defect models. Difference in volume of the thoracic cavity between inspiration and expiration phases was viewed as the indicator of respiratory function and was defined as ΔV. The values of ΔV were compared between normal type models and their corresponding defect type models. RESULTS: Among the six types of defect, the degree of functional loss was greatest with those defects on the lateral-inferior part of the thorax, where ΔV of the affected side hemithorax drops to 38 to 45% of normal values, whereas ΔV was 62 to 88% with other defect models. CONCLUSION: Thoraces that have defects on their lateral-inferior regions present lower respiratory functioning than thoraces with other defect locations. Hence, in treating clinical cases where defects are expected to occur in this region, effort should be made to minimize the area of the defect.

Risk scores for predicting mortality after surgical ventricular reconstruction for ischemic cardiomyopathy: results of a Japanese multicenter study.

OBJECTIVES: Surgical ventricular reconstruction has been believed to be beneficial for those with ischemic cardiomyopathy. However, the effectiveness of surgical ventricular reconstruction was not proved by a large-scale trial, and no report has clearly demonstrated the exact indications and limitations of surgical ventricular reconstruction. The purpose of this study was to elucidate predictive factors of mortality after surgical ventricular reconstruction and to develop a prognostic model by calculating risk scores. METHODS: The study subjects were 596 patients who underwent surgical ventricular reconstruction for chronic ischemic heart failure in 11 Japanese cardiovascular hospitals between 2000 and 2010. Potential predictors of postoperative mortality were assessed using the Cox proportional hazards model, and a risk score was calculated. RESULTS: Forty-one patients died before discharge, and 81 patients died during a mean follow-up time of 2.9 years. Four independent predictors of mortality were identified: age, Interagency Registry for Mechanically Assisted Circulatory Support profile, left ventricular ejection fraction, and severity of mitral regurgitation. Each variable was assigned a number of points proportional to its regression coefficient. A risk score was calculated using the point scores for each patient, and 3 risk groups were developed: a low-risk group (0-4 points), an intermediate-risk group (5-6 points), and a high-risk group (7-12 points). Their 3-year survivals were 93%, 81%, and 44%, respectively (log-rank P < .001). Harrell's C-index of the predictive model was 0.69. CONCLUSIONS: A simple prognostic model was developed to predict mortality after surgical ventricular reconstruction. It can be useful in clinical practice to select treatment options for ischemic heart failure.

Long-term outcomes and comparison after conventional coronary artery bypass grafting for left main disease between patients classified as percutaneous coronary intervention recommendation classes II and III.

OBJECTIVES: We retrospectively analysed long-term outcomes after conventional coronary artery bypass grafting (CABG) between patients having left main (LM) disease who should have been assigned class II and those assigned class III recommendation for percutaneous coronary intervention (PCI) according to the 2010 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines. METHODS: From January 2000 to December 2009, conventional CABG was routinely employed in 180 consecutive patients with previously untreated and stable LM lesion. A comparison between two groups (CABG for PCI class II and CABG for PCI class III) was performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, stroke [cerebral vascular accident (CVA)], myocardial infarction (MI) and repeat revascularization. We also analysed the effects of variables on MACCE at 8 years after the operation. RESULTS: The overall 8-year MACCE rates were significantly lower in the CABG for PCI class II group than in the CABG for PCI class III group (9.7% class II vs 31.1% class III; P = 0.0005). This was largely because of an increased rate of repeat revascularization (1.2% class II vs 13.8% class III; P = 0.0029). The cumulative rate of the combined outcomes of all death/CVA/MI was significantly lower in the CABG for PCI class II group (8.5% class II vs 19.2% class III; P = 0.048); there was no observed difference between the groups for all-cause death, CVA and MI. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes (Death/CVA/MI) at 8 years [odds ratio (OR) 1.05, P = 0.023], repeat revascularization at 8 years (OR 1.11, P = 0.0013) and MACCE at 8 years (OR 1.07, P < 0.0001). CONCLUSIONS: In our routine strategy of conventional CABG for LM disease, patients believed to be PCI candidates for LM disease have significantly better long-term outcomes as characterized by combined outcomes (Death/CVA/MI), repeat revascularization and MACCE. These results provide a suitable benchmark against which long-term outcomes of PCI for LM disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after CABG for LM disease.