Preoperative exercise capacity is associated with the prevalence of postoperative delirium in elective cardiac surgery.

BACKGROUND: Postoperative delirium (POD) is a critical complication that is closely associated with mortality and major morbidity in elective cardiac surgery. The identification of patients at risk for POD is crucial but has not been fully explored. AIMS: The aim of this study was to determine the predictive value of the assessment of preoperative exercise capacity for POD. METHODS: We enrolled 313 consecutive patients (mean age, 68.6 ± 14.8 years) undergoing elective cardiac surgery. We measured physical functions such as the 6-minute walking distance (6MWD) and Timed Up-and-Go test (TUG) before surgery. The assessment of delirium was conducted every 8 h from the day of surgery to 5 days after surgery using the Intensive Care Delirium Screening Checklist. RESULTS: POD occurred in 46 patients (14.6%). Age, 6MWD, TUG, serum hemoglobin, estimated glomerular filtration rate, and length of intensive care unit stay were significantly different based on the presence or absence of POD (p < 0.05 for each). After multivariate analysis, 6MWD remained a statistically significant indicator for developing POD (OR 0.98; p = 0.02). The cut-off value of 6MWD for predicting POD was 345 m (AUC = 0.75; p = 0.001). CONCLUSIONS: Poor exercise capacity was found to be an independent predictor of POD following elective cardiac surgery. This finding suggests the importance of preoperative functional evaluation in the prevention and management of POD in cardiac surgery patients.

Poor preoperative nutritional status is an important predictor of the retardation of rehabilitation after cardiac surgery in elderly cardiac patients.

BACKGROUND: Preoperative nutritional status and physical function are important predictors of mortality and morbidity after cardiac surgery. However, the influence of nutritional status before cardiac surgery on physical function and the progress of postoperative rehabilitation requires clarification. AIMS: To determine the effect of preoperative nutritional status on preoperative physical function and progress of rehabilitation after elective cardiac surgery. METHODS: We enrolled 131 elderly patients with mean age of 73.7 ± 5.8 years undergoing cardiac surgery. We divided them into two groups by nutritional status as measured by the Geriatric Nutritional Risk Index (GNRI): high GNRI group (GNRI ≥ 92, n = 106) and low GNRI group (GNRI < 92, n = 25). Physical function was estimated by handgrip strength, knee extensor muscle strength (KEMS), the Short Physical Performance Battery (SPPB), and 6-minute walk test (6MWT). Progress of postoperative rehabilitation was evaluated by the number of days to independent walking after surgery, length of stay in the ICU, and length of hospital stay. RESULTS: After adjusting for potential confounding factors, preoperative handgrip strength (P = 0.034), KEMS (P = 0.009), SPPB (P < 0.0001), and 6MWT (P = 0.012) were all significantly better in the high GNRI group. Multiple regression analysis revealed that a low GNRI was an independent predictor of the retardation of postoperative rehabilitation. CONCLUSIONS: Preoperative nutritional status as assessed by the GNRI could reflect perioperative physical function. Preoperative poor nutritional status may be an independent predictor of the retardation of postoperative rehabilitation in patients undergoing elective cardiac surgery.

Impact of positional relationship of commissures on cusp function after valve-sparing root replacement for regurgitant bicuspid aortic valve.

OBJECTIVES: The aim of this study is to investigate the longitudinal valve function after valve-sparing root replacement in patients with bicuspid aortic valves (BAVs), in terms of both transvalvular pressure gradient (TVPG) and freedom from aortic regurgitation. METHODS: In this non-randomized retrospective study, two different approaches were chosen for correcting the circumferential orientation of commissures during aortic root reimplantation for Sievers type I BAV: (i) 180° orientation, in which both cusps occupy equal surface areas and (ii) preserving native commissural orientation. From 2005 to 2015, 41 consecutive patients with Sievers type I BAV undergoing valve-sparing root replacement were divided into two groups according to the techniques: native orientation group and 180° group. RESULTS: The native orientation group included 22 patients (age, 45.1 ± 13.6 years) and the 180° group included 19 patients (age, 36.6 ± 13.7 years; P = 0.053). There was no significant difference in preoperative variables between the two groups. Postoperative and follow-up echocardiography revealed the following: the average TVPG at the time of discharge in the native orientation and the 180° groups was 17.3 ± 6.6 and 21.7 ± 11.1 mmHg (P = 0.16), respectively, at peak and 10.0 ± 3.7 and 11.7 ± 6.0 mmHg (P = 0.33), respectively, at mean; at follow-up, the corresponding values were 19.1 ± 6.6 and 22.9 ± 10.6 mmHg (P = 0.24) at peak and 9.9 ± 3.8 and 13.2 ± 7.2 mmHg (P = 0.12) at mean. Thus, there was a trend towards higher TVPG in the 180° group. The difference between the preoperative and postoperative commissural angles was correlated with higher postoperative peak and mean TVPG (r = 0.53, P = 0.041, 95% confidence interval, 0.029-0.82 at peak and r = 0.58, P = 0.024, 95% confidence interval, 0.092-0.84 at mean). CONCLUSIONS: In terms of freedom from aortic regurgitation and valve function, similar outcomes were achieved in both despite different repair techniques used for fixation of commissures during valve-sparing aortic root replacement in BAV. However, attention should be paid to patients with 180° commissural reposition because of a trend towards higher TVPG.

Left ventricular outflow tract obstruction caused by massive mitral annular calcification in a patient with hypertensive heart disease.

Mitral annular calcification (MAC) is frequently observed, but it rarely causes left ventricular outflow tract (LVOT) obstruction (LVOTO). An 83-year-old woman with hypertension, diabetes, and dyslipidemia was admitted to our hospital because of exertional dyspnea. She was diagnosed with hypertensive heart disease. Her symptoms were exacerbated by exertion, and she had no symptoms at rest. Transthoracic echocardiography showed massive posterior MAC, a sigmoid septum, and LVOTO, with a peak gradient of 15.4 mmHg at rest. Systolic anterior motion of the anterior mitral leaflet was not found. Moreover, the LVOT gradient in the stress condition was evaluated, and an increased LVOT gradient (47.3 mmHg) and chest discomfort was noted after 20 µg/kg/min of dobutamine was administered and the Valsalva maneuver was used. Hence, the patient was diagnosed with latent LVOTO. Interestingly, the distance between the septal wall, which was protruding into the left ventricular cavity, and the mitral valve coaptation, which was pushed up by the posterior MAC, had become closer, causing dynamic LVOTO. Since it is difficult to treat LVOTO with medication, ultimately, septal myectomy and mitral valve replacement were performed, which improved her symptoms. Evaluating the LVOT pressure gradient in stress condition is important in patients with MAC. .

Spontaneous pseudoaneurysm of the hand.

Pseudoaneurysm of the hand is rare. Few cases have been reported in the literature, and these cases are usually related to trauma. Early treatment is recommended for pseudoaneurysm after it has been diagnosed. We report the surgical treatment of spontaneous pseudoaneurysm of the hand in a patient who was undergoing anticoagulant therapy.

Volume reduction rate by surgical ventricular restoration determines late outcome in ischaemic cardiomyopathy.

AIMS: Surgical ventricular restoration (SVR) effectively reduces left ventricular (LV) volume in ischaemic cardiomyopathy (ICM), but the recent Surgical Treatment of Ischemic Heart Failure (STICH) Trial questions its importance. We report 8-year SVR experience in patients with ICM. METHODS AND RESULTS: Between 2000 and 2008, 135 patients underwent SVR for ICM. This report analyses data from 90 patients who underwent accurate pre- and post-operative assessment of LV volumes by left ventriculogram or scintigram. All patients also had echocardiograms. Pre-operative LV end-systolic volume index (ESVI) was 123.5 ± 53.2 mL/m(2) (range 92-310). Overall, 63 patients were in NHYA class III and 27 were in class IV. The SVR procedure was endoventricular circular patch plasty in 33 patients, septal-anterior ventricular exclusion in 43, and 14 patients had posterior exclusion. Coronary artery bypass grafting was performed in 78 patients (87%) and 50 underwent mitral procedures. Eighteen follow-up late deaths occurred owing to chronic heart failure (n = 12) and sudden death (n = 6). Post-operative ESVI was < 90 mL/m(2) (Group-S) in 54 patients, 90-120 mL/m(2) (Group-M) in 16, and >120 mL/m(2) (Group-L) in 20 patients. The 8-year survival rate was 82.4% in group-S following a > 33% LV volume reduction. In contrast, in Group-M and Group-L, the volume reduction was ∼ 15%, and 100% of patients died within 7 years following the SVR procedure (or 0% 8-year survival). CONCLUSIONS: SVR is most effective when a >33% volume reduction rate achieves an ESVI of < 90 mL/m(2). No long-term benefits occur when SVR induces an LV volume reduction of < 15% leaving a residual ESVI >90 mL/m(2). This database contradicts the STICH trial findings.

[Surgical treatment for atrial fibrillation using ablation devices and ablation of autonomic ganglion plexi].

BACKGROUND: Development of ablation device for the surgical treatment for atrial fibrillation (Af) has suggested the safety and easiness of the maze procedure. However, the success rate of sinus rhythm (SR) recovery is not satisfactory. We studied the maze procedure and the results with ablation device and also with additional ganglion plexi (GP) ablation. PATIENTS AND METHODS: Since April in 2002, 269 patients received maze operation with ablation device. The etiology was valvular disease in 196, ischemic heart disease in 18, dilated cardiomyopathy (DCM) in 36, and others in 19. The full maze operation with ablation devices and cryoablation was performed in principle and monopolar ablation devices were used in early phase and the bipolar ablation device was applied thereafter. The 73 patients after October in 2007 were divided into 44 patients with simultaneous GP ablation and 29 patients without GP ablation and the recovery rate of SR was compared in the 2 groups. RESULTS: There were 7 hospital deaths (5 in DCM and 2 in valve disease). After the operation, 79% of the patients with monopolar devices and 75% of the patients with bipolar device were in SR. Among them, 88% of the patients with simultaneous GP ablation were in SR and no major complication. CONCLUSION: The full maze operation with bipolar ablation and cryoablation showed minimal operative risk and concomitant GP ablation improved the SR recovery rate after the operation.

Indication of posterior restoration and surgical results in patients with dilated cardiomyopathy.

OBJECTIVE: Nontransplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. Anterior restoration for anterior akinesis has shown favourable outcome. Posterior restoration and surgical results are also discussed. METHODS: At the Hayama Heart Center in Japan, between 2005 and 2009, posterior restoration for DCM was performed in 36 patients (10 with ischaemic and 26 with nonischaemic, including muscular dystrophy in three). There were 32 men and four women with a mean age of 53 years. The mean preoperative ejection fraction was 23% and the preoperative New York Heart Association (NYHA) classification was class III in 16 patients and class IV in 20 with eight emergent operations. To identify the posterior lesion before operation, speckle-tracking echocardiography was used, with a Vivid 7 ultrasound machine. The short-axis images from the middle level of the left ventricle (LV) were obtained to assess myocardial segmental viability. Based on the results of speckle-tracking echocardiography, posterior restoration was performed in patients with postero-lateral akinesis and septal kinesis. After the cardioplegic arrest, mitral plasty or coronary artery bypass grafting (CABG) was performed and the posterior LV muscle between bilateral papillary muscles was partially resected under beating heart. The LV apex was preserved and cryoablation was applied between the cut edge and the mitral annulus. All the patients were followed with cardiac echocardiography. RESULTS: In addition to LV restoration, mitral plasty was successfully performed in all the patients. Concomitant CABG was performed in seven, tricuspid surgery in 11 and cardiac resynchronisation therapy (CRT) in eight. Perioperative intra-aortic balloon pumping (IABP) was used in six and there was no hospital mortality, including eight emergent operations. After the operation, 29 patients (80.6%) improved their functional class into class I or II. In the late follow-up, there were two cardiac deaths and one noncardiac death and the 4-year survival rate was 85.8%. CONCLUSIONS: The site selection with speckle-tracking echocardiography demonstrated the accurate akinetic lesion of the posterior LV wall. The posterior restoration with preservation of bilateral papillary muscles and LV apex based on the site selection improved operative and mid-term results in the selected patients with DCM.

Aortic root replacement with a stentless bioprosthesis in osteogenesis imperfecta.

Herein is reported a successful surgical case of aortic root replacement for aortic regurgitation in a patient with osteogenesis imperfecta. A 37-year-old male, who had been diagnosed as osteogenesis imperfecta of type IA, underwent mitral valve repair for mitral regurgitation. Severe aortic regurgitation developed four years after surgery. A stentless bioprosthesis was implanted using the full root technique for fear of progressive dilatation of the sinus of Valsalva or aortic dissection, which is well documented in osteogenesis imperfecta. Aortic root replacement with a stentless bioprosthesis for aortic regurgitation represents an alternative procedure of choice for a patient with osteogenesis imperfecta.

Two surgical cases of acute aortic dissection in pregnancy with marfan syndrome.

We describe 2 surgical cases of acute aortic type A dissection during pregnancy in women with Marfan syndrome. Both of them underwent emergency aortic root replacement under deep hypothermia; one patient was in her 21(st) week of pregnancy and the other was treated 1 day after a normal delivery. The patients experienced fair postoperative courses, but intrauterine fetus death was confirmed in the first case.

Primary cardiac liposarcoma causing cardiac tamponade: report of a case.

The intracardiac growth and extension of liposarcoma was observed in a 60-year-old woman. The epicardial tumor was identified to originate from the anterior wall of the right ventricle. She initially showed symptoms associated with cardiac tamponade. A surgical operation was performed but it resulted in incomplete resection due to massive invasion and dissemination. The recurrence of the tumors led to congestive heart failure. Finally, she died of heart failure and liver dysfunction as a result of tumor metastasis and invasion. An autopsy detected the primary cardiac liposarcoma. Only a few cases of cardiogenic liposarcoma have so far been reported. A further elucidation of cardiac liposarcoma could reveal mechanisms of the disease, and thus contribute to development of complementary therapies after surgical intervention.

Reoperation for early failure of a freestyle bioprosthesis using a full root technique.

The case is reported of a 65-year-old male who required reoperation for early failure of a Freestyle stentless valve aortic root bioprosthesis implanted using the full root technique. The bioprosthesis had been implanted to treat annuloaortic ectasia associated with severe aortic regurgitation (AR). At 18 months postoperatively, a new diastolic murmur developed, though without complaint by the patient. Transthoracic echocardiography demonstrated severe AR with aneurysmal dilatation of the non-coronary porcine sinus of Valsalva. Pseudoaneurysm formation, associated with perforation of the non-coronary sinus of Valsalva of the bioprosthesis, was observed at surgery. On inspection, the pseudoaneurysm had pushed the commissures inward, and had created severe aortic valve regurgitation. No infection or calcification was detected on the Freestyle valve, and the aortic root was successfully reconstructed using a composite graft.

[Chordal cutting for the treatment of ischemic mitral regurgitation: two case reports].

The surgical treatment for ischemic mitral regurgitation remains controversal. Ring annuloplasty results in recurrent mitral regurgitation in some cases. Strut chordal cutting is a new surgical procedure in addition to ring annuloplasty for ischemic mitral regurgitation. Two patients (63-year-old woman, 53-year-old man) with severe ischemic mitral regurgitation were treated with this procedure. The patients had congestive heart failure due to mitral regurgitation, associated with inferior myocardial infarction. Regurgitant fraction of mitral regurgitation was 70% and 52% before surgery. Mitral leaflet tethering caused by apical displacement of the papillary muscle was observed. Mitral valve repair was performed by ring annuloplasty and chordal cutting. Intraoperative echocardiography showed that chordal cutting improved the configuration of the anterior leaflet, resulting in good mitral valve coaptation without regurgitation.