Mitral valve repair using a semi-rigid posterior band: a 10-year Japanese single-center experience of 244 patients.

Background: Mitral valve repair (MVr) is an established procedure for patients who require surgery for primary mitral regurgitation (PMR). The Colvin-Galloway Future Band (CGFB) is a semi-rigid posterior band expected to improve the clinical outcomes of MVr. However, information on the hemodynamic and functional performance and long-term outcomes of CGFB is limited. We evaluated the quality, durability, and clinical performance after MVr using CGFB for PMR as the cohort study. Methods: A total of 244 patients who underwent MVr with CGFB were enrolled. Clinical and echocardiographic assessments were performed (mean follow-up period, 4.0±2.4 years). Results: Posterior mitral leaflet resection was the most common MVr procedure. CGFBs measuring 28 mm (35.2%) and 30 mm (36.5%) were used. The incidence of systolic anterior motion (SAM) was 1.6%. A total of 93.4% of the patients had no or trace MR at discharge. Over 90% of patients had no or mild MR at the last follow-up. The mean pressure gradient and mitral valve orifice area one year after MVr ranged between 2.6 and 3.6 mmHg and 2.3 and 3.4 cm2, respectively. At follow-up, 85.4% of the patients were New York Heart Association class I. Three patients underwent repeat mitral valve surgery. Conclusions: The CGFB demonstrates satisfactory quality and durability in MVr for PMR. Other advantages include a low occurrence of SAM and acceptable hemodynamic outcomes, particularly in patients requiring a smaller annuloplasty device.

Early thrombus formation including hypo-attenuated leaflet thrombosis after surgical bioprosthetic aortic valve replacement.

OBJECTIVE: To assess the occurrence, predictors, and outcomes of hypo-attenuated leaflet thickening (HALT) and thrombus outside the prosthetic valve following surgical aortic valve replacement. METHODS: A total of 118 patients underwent surgical aortic valve replacement with bioprosthetic valves between July 2020 and June 2022. Sixty-two (52.5%) patients, which is a fairly high number of patients, underwent cardiac computed tomography and transthoracic echocardiography one week after surgery. Patients were divided into two groups, those with HALT (n = 14) and those without HALT (n = 48). RESULTS: Of the 62 patients who underwent cardiac computed tomography, HALT was observed in 14 (22.5%) patients during the very early postoperative phase. Reduced leaflet motion was observed in two of the 14 patients. The low-attenuation areas were located outside the prosthetic valve in 10 cases (71.4%) in the HALT group and in 14 cases (29.2%) in the non-HALT group. More than 50% of patients (57.1%) with HALT and 79.2% without HALT were administered warfarin. Neither in-hospital deaths nor postoperative thromboembolic events were observed during hospitalization. No patient had a mean pressure gradient > 20 mmHg in either group. CONCLUSION: HALT was observed in one-fifth of the cases after surgical aortic valve replacement during the very early postoperative phase in an institution wherein administration of continuous heparin infusion after surgery is a standard practice. HALT did not affect the early prognosis or incidence of cerebral infarction.

Endovascular Aortic Repair for Heavily Calcified Abdominal Aortic Stenosis Using the Gore Viabahn Vbx Balloon-Expandable Covered Stent.

Open surgery for the treatment of focal infrarenal aortic stenosis in high-risk patients may result in complications and mortality. Endovascular aortic repair may be used to treat these lesions. Here, we present the case of a 78-year-old woman with severe, highly calcified stenosis of the infrarenal abdominal aorta, which was successfully treated with the GORE VIABAHN VBX (Gore Medical; Flagstaff, AZ) balloon-expandable covered stent. Long-term and randomized controlled studies comparing open surgery with EVAR are necessary to evaluate the usefulness of this novel device.

[Result of Surgical Treatment for Active Infective Endocarditis at the Aortic Position].

Herein, we retrospectively review our experience with surgical treatment of active aortic valve infective endocarditis, particularly aortic annular abscess, and central nervous system complications. From 2012 to 2021, 46 consecutive patients underwent surgery during the active phase of infective endocarditis, 25 of which were performed at the aortic position. One patient died early (<30 days) due to low output syndrome and another 2 patients who were never discharged died because of general prostration. The actuarial survival rate was 84% at 1 year, and 80% at 3 and 5 years. Eleven patients [6 native valve endocarditis (NVE), 5 prosthetic valve endocarditis (PVE)] had valve annular abscess requiring removal of the infected tissue and reconstruction of a definite anatomic continuity, and aortic valve replacement was subsequently performed in 7 patients and aortic root replacement in 4 patients. Direct closure was performed in 4 patients with partial annulus defects, and reconstruction with an autologous nor bovine pericardium patch was performed in 6 patients with large annulus defects. Preoperative imaging revealed acute cerebral embolism in 10 patients. In eight cases, surgery was performed within 7 days after diagnosis of cerebral embolism. No patient had abnormal postoperative neurological findings. There were no reoperations and no recurrence of infective endocarditis.

ECPELLA as the bridge to surgery in patients with cardiogenic shock due to post-infarct papillary muscle rupture: management of mechanical circulatory support during operation.

Papillary muscle rupture is a fatal complication with a high operative mortality. Most patients experience cardiogenic shock and hypoxia due to pulmonary edema caused by severe mitral regurgitation. Although preoperative stabilization using a mechanical assist device potentially improves surgical outcomes, an appropriate strategy has not yet been established. ECPELLA, combining venoarterial extracorporeal membrane oxygenation and Impella, has the potential to stabilize preoperative status and improve outcome in patients with refractory cardiogenic shock due to papillary muscle rupture. Herein, we present 3 cases involving the efficacy of ECPELLA and our tips of surgical and ECPELLA management in patients with papillary muscle rupture.

Quantitative environmental DNA metabarcoding shows high potential as a novel approach to quantitatively assess fish community.

The simultaneous conservation of species richness and evenness is important to effectively reduce biodiversity loss and keep ecosystem health. Environmental DNA (eDNA) metabarcoding has been used as a powerful tool for identifying community composition, but it does not necessarily provide quantitative information due to several methodological limitations. Thus, the quantification of eDNA through metabarcoding is an important frontier of eDNA-based biomonitoring. Particularly, the qMiSeq approach has recently been developed as a quantitative metabarcoding method and has attracted much attention due to its usefulness. The aim here was to evaluate the performance of the qMiSeq approach as a quantitative monitoring tool for fish communities by comparing the quantified eDNA concentrations with the results of fish capture surveys. The eDNA water sampling and the capture surveys using the electrical shocker were conducted at a total of 21 sites in four rivers in Japan. As a result, we found significant positive relationships between the eDNA concentrations of each species quantified by qMiSeq and both the abundance and biomass of each captured taxon at each site. Furthermore, for seven out of eleven taxa, a significant positive relationship was observed between quantified DNA concentrations by sample and the abundance and/or biomass. In total, our results demonstrated that eDNA metabarcoding with the qMiSeq approach is a suitable and useful tool for quantitative monitoring of fish communities. Due to the simplicity of the eDNA analysis, the eDNA metabarcoding with qMiSeq approach would promote further growth of quantitative monitoring of biodiversity.

In vivo efficacy of a polymer layered decellularized matrix composite as a cell honing cardiovascular tissue substitute.

Cardiovascular surgery involves reconstruction of tissues that are under cyclical mechanical loading, and in constant contact with pulsatile blood flow. Durable biomaterials for such tissue reconstruction are scarce, as they need to be mechanically strong, hemocompatible, and resist structural deterioration from calcification. While homografts are ideal, they are scarce; xenografts are immunogenic and rendered inactive from glutaraldehyde fixation, causing them to calficy and structurally deteriorate over time; decellularized xenografts are devoid of cells, mechanically weak; and synthetic polymeric scaffolds are thrombogenic or too dense to enable host cell infiltration. In this work, we report the in vivo feasibility of a new polymer-decellularized matrix composite material (decellularized bovine pericardium-polycaprolactone: chitosan) fabricated by electrospinning, which is designed to be mechanically strong and achieve programmed host cell honing to integrate into the host. In a rodent and sheep model, this new material was found to be hemocompatible, and enabled host cell infiltration into the polymer and the decellularized matrix core underlying the polymer. Presence of M2 macrophages and several vascular cell types, with matrix remodeling in the vicinity of the cells was observed in the explanted tissues. In summary, the proposed composite material is a novel approach to create in-situ host integrating tissue substitutes, with better non-thrombogenicity, reduced infections and endocarditis, and potentially the ability to grow with the patient and remodeling into a native tissue structure.

Right-parasternal approach for aortic valve replacement and ascending aortic repair after ante-thoracic route gastric tube reconstruction.

Due to the limitations of surgical incisions and approaches brought on by the presence of gastric tube (GT), open heart surgery following ante-thoracic route GT reconstruction remains challenging. A-73-year-old man, who had a history of esophageal resection and ante-thoracic route GT reconstruction required aortic valve replacement (AVR) concomitant with ascending aortic repair (AAR) for aortic stenosis and dilated ascending aorta. We performed open heart surgery via a right-parasternal approach to avoid injury to the GT and nutrient arteries. This approach provided a good operative field, similar to median sternotomy. To our knowledge, this is the first case of AVR concomitant with AAR after ante-thoracic route GT reconstruction via a right-parasternal approach. We consider that the right-parasternal approach is reasonable for patients with ante-thoracic route GT reconstruction.

Hypo-attenuated leaflet thickening after Perceval sutureless bioprosthesis implantation.

Modern multi-slice computed tomography (CT) has increased the detection of hypo-attenuated leaflet thickening (HALT). Furthermore, HALT's impact on transcatheter or surgical biological aortic valve (AV) prostheses has attracted attention. However, few reports on HALT in sutureless bioprostheses exist. Herein, we report a case of early structural valve deterioration due to HALT after AV replacement (AVR) with a Perceval bioprosthesis, which improved after anticoagulation therapy. A 79-year-old man admitted to our hospital with paroxysmal atrial fibrillation (PAF) during hemodialysis was also diagnosed with AV stenosis and, coronary artery disease, and PAF. He underwent AVR, coronary artery bypass grafting, and left atrial appendage resection. Although the postoperative course was uneventful with dual antiplatelet therapy, postoperative enhanced CT revealed HALT with reduced leaflet motion, and echocardiography showed an increased transvalvular pressure gradient. After using warfarin with target prothrombin time-international normalized ratio of 2-2.5 and/or heparin with target activated partial thromboplastin time of 45-60 s, the HALT disappeared with an improved transvalvular pressure gradient without any thromboembolic events.

Anterior Papillary Muscle Rupture due to Acute Myocardial Microinfarction of the Small High Lateral Branch.

Papillary muscle rupture is a catastrophic condition, of which most cases manifest posterior papillary muscle rupture. Anterior papillary muscle rupture is a rare condition. Particularly, anterior papillary muscle rupture due to acute myocardial microinfarction of the small high lateral branch is extremely rare. Since papillary muscle rupture can occur even in such a small branch or small area due to myocardial infarction, echocardiographic and/or ventriculographic confirmation is essential in cases of sudden worsening of heart failure. Herein, we report the case of anterior papillary muscle rupture with a good outcome. A 61-year-old man was admitted to our hospital with cardiogenic shock. Echocardiography revealed severe mitral regurgitation due to papillary muscle rupture. Coronary angiography demonstrated high-grade stenosis in the high lateral branch. However, no other significant stenoses were found. Emergency mitral valve replacement was performed. The patient was discharged 19 days after surgery without any complications.

Intimo-Intimal Intussusception due to Stanford Type A Acute Aortic Dissection Presenting as Cerebral Infarction.

Complete circumferential dissection is a rare clinical presentation of aortic dissection, wherein the dissected flap has the potential to cause intimo-intimal intussusception, which can lead to several catastrophic complications. We report a case of Stanford type A acute aortic dissection with intimo-intimal intussusception causing unstable cerebral ischemic symptoms. An 82-year-old man was taken to another hospital with severe intermittent dizziness. Head magnetic resonance imaging revealed multiple right-hemispheric cerebral infarctions. Computed tomography also showed a "missing flap," indicating that the intimal flap was observed in the aortic root and arch but not in the ascending aorta. The patient was referred to our hospital for emergent surgery. Intraoperatively, the intimal tear was found to be circumferential, and the transected intima was folded and superimposed from the origin of the brachiocephalic artery to the aortic arch. Ascending aortic replacement and aortic valve replacement were performed; the postoperative course was good.

Ventricular reshaping with a beating heart implant improves pump function in experimental heart failure.

OBJECTIVE: The left ventricle remodels from an ellipsoidal/conical shape to a spherical shape after a myocardial infarction. The spherical ventricle is inefficient as a pumping chamber, has higher wall stresses, and can lead to congestive heart failure. We sought to investigate if restoring physiological ventricular shape with a beating heart implant improves pump function. METHODS: Rats were induced with a myocardial infarction, developing left ventricular dilatation and dysfunction, and becoming spherical over 3 weeks. Thereafter, they were randomized to undergo left ventricular reshaping with a beating heart implant (n = 19) or continue follow-up without an implant (n = 19). Biweekly echocardiography was performed until 12 weeks, with half the rats euthanized at 6 weeks and remaining at 12 weeks. At termination, invasive hemodynamic parameters and histopathology were performed. RESULTS: At 3 weeks after the infarction, rats had a 22% fall in ejection fraction, 31% rise in end diastolic volume, and 23% rise in sphericity. Transventricular implant reshaping reduced the volume by 12.6% and sphericity by 21%, restoring physiologic ventricular shape and wall stress. Over the 12-week follow-up, pump function improved significantly with better ventricular-vascular coupling in the reshaped hearts. In this group, cardiomyocyte cross-section area was higher and the cells were less elongated. CONCLUSIONS: Reshaping a postinfarction, failing left ventricle to restore its physiological conical shape significantly improves long-term pump function.

Hemodynamic and clinical performance of the 25-mm Medtronic Mosaic porcine bioprosthesis in the mitral position.

The 25-mm Medtronic Mosaic porcine bioprosthesis (MB25) is the smallest bioprosthesis that has been approved for use in the mitral position in Japan. Various studies have reported satisfactory hemodynamic performance and good long-term outcomes of the Medtronic Mosaic porcine bioprosthesis. However, the hemodynamic and clinical performances of the MB25 in the mitral position remain unknown. This study aimed to evaluate the hemodynamic and clinical performance of the MB25 in mitral valve replacement (MVR). Twenty patients who underwent MVR using the MB25 between February 2013 and April 2018 were studied. We evaluated the hemodynamic performance of the MB25, cardiac chamber size, cardiac function, and systolic pulmonary artery pressure (PAP) using echocardiography during follow-up. The study outcomes were major adverse cardiac events (MACEs) and all-cause mortality. Sixteen patients (80%) had a patient prosthesis mismatch defined as an index effective orifice area of ≤ 1.2 cm2/m2. The left atrial dimension was significantly reduced after surgery (p = 0.0282). The mean pressure gradients (MPG) in the mitral position were 5.5 ± 1.7 mmHg at discharge and 4.2 ± 1.3 mmHg at 1 year postoperatively. The MPG in the mitral position significantly decreased during the follow-up period (p = 0.0489). Systolic PAP significantly improved postoperatively. The 1-, 3-, and 5-year survival rates were 87, 79, and 70%, respectively. No cardiac death occurred. There were no MACEs or reports of structural valve degeneration during the follow-up period. The hemodynamic and clinical performances of the MB25 in the mitral position were satisfactory as the smallest biological mitral valve. The MB25 is a reasonable option for MVR to reduce the surgical difficulty in high-risk patients with an advanced age, a small body size or MAC and when recurrent MVR or complex procedures are performed.

Image-Guided Targeted Mitral Valve Tethering with Chordal Encircling Snares as a Preclinical Model of Secondary Mitral Regurgitation.

Development of transcatheter mitral valve interventions has ushered a significant need for large animal models of secondary mitral regurgitation. Though currently used heart failure models that chronically develop secondary mitral regurgitation are viable, the severity is lower than patients, the incubation time is long, and mortality is high. We sought to develop a swine model of acute secondary mitral regurgitation that uses image-guided placement of snares around the mitral chordae. Twenty-seven adult swine (n = 27) were assigned to secondary mitral regurgitation induced by valve tethering with image-guided chordal encircling snares (group 1, n = 7, tether MR (tMR)); secondary mitral regurgitation by percutaneous posterolateral myocardial infarction causing ventricular dysfunction and regurgitation (group 2, n = 6, functional MR (fMR)); and control animals (group 3, n = 14). Regurgitant fraction in tMR was 42.1 ± 14.2%, in fMR was 22 ± 9.6%, and in controls was 5.3 ± 3.8%. Mitral tenting height was 9.6 ± 1.3 mm in tMR, 10.1 ± 1.5 mm in fMR, and 5.8 ± 1.2 mm in controls. Chordal encircling tethers reproducibly induce clinically relevant levels of secondary mitral regurgitation, providing a new animal model for use in translational research.

Effect of early versus late onset mitral regurgitation on left ventricular remodeling in ischemic cardiomyopathy in an animal model.

BACKGROUND: Patients who survive a myocardial infarction have progressive cardiac dysfunction and ventricular remodeling. Mitral regurgitation is often diagnosed in these patients, and is a risk factor that portends poor prognosis. Whether such postinfarction mitral regurgitation magnifies adverse left ventricular remodeling is unclear, which was studied in an animal model. METHODS: Forty-one adult rats were induced with myocardial infarction using left coronary artery ligation and assigned to 3 groups: group 1, myocardial infarction only; group 2, myocardial infarction with severe mitral regurgitation introduced after 4 weeks; and group 3, myocardial infarction with severe mitral regurgitation introduced after 10 weeks. Valve regurgitation was introduced by advancing a transapical ultrasound-guided needle into the mitral valve anterior leaflet. Animals were survived to 20 weeks from the index procedure, with biweekly cardiac ultrasound, and invasive hemodynamics and histology at termination. RESULTS: At 20 weeks, end diastolic volume was largest in the groups with mitral regurgitation, compared with the group without the valve lesion (group 1, 760.9 ± 124.6 µL; group 2, 958.0 ± 115.1 µL; group 3, 968.3 ± 214.9 µL). Similarly, end systolic volume was larger in groups with regurgitation (group 1, 431.2 ± 152.6 µL; group 2, 533.2 ± 130.8 µL; group 3, 533.1 ± 177.5 µL). In the infarction-only group, left ventricular remodeling was maximal until 6 weeks and plateaued thereafter. In groups with mitral regurgitation, left ventricular remodeling was significantly elevated at the onset of regurgitation and persisted. CONCLUSIONS: Mitral regurgitation is a potent driver of adverse cardiac remodeling after a myocardial infarction, irrespective of the timing of its onset.

Evaluation of hemodynamics after mitral valve replacement with the St Jude Medical Epic bioprosthesis: a Japanese single-center experience.

To assess the early hemodynamics after mitral valve replacement (MVR) using the St Jude Medical (SJM) Epic bioprosthesis. MVR was performed using the SJM Epic bioprosthesis in 35 patients from June 2018 to April 2020; three patients were excluded because the postoperative transthoracic echocardiography (TTE) data were unavailable. Data from postoperative TTE at 1 week and 3 months after the procedure were reviewed. The mean mitral pressure gradient (mMPG) was calculated using a continuous wave Doppler method. Left ventricular outflow tract (LVOT) was calculated using a pulse wave Doppler method. The effective orifice area (EOA) was measured from pressure half time. There were 12 men (37.5%) and 20 women (62.5%) with a mean age of 75.9 years (61-88 years). The mean body surface area was 1.51 ± 0.22 cm2. The 25 mm and 27 mm valves were used in more than 50% of cases. The mMPG was 4.9 ± 1.7 mmHg and 5.4 ± 1.6 mmHg at 1 week and 3 months after surgery, respectively. EOA was 2.18 ± 0.50 cm2 and 2.31 ± 0.59 cm2 at 1 week and 3 months after surgery, respectively. The peak velocity of the LVOT (n = 22) was 103.3 ± 21.3 cm/s and 106.8 ± 27.4 cm/s at 1 week and 3 months after surgery, respectively. No findings suggested paravalvular regurgitation and LVOT obstruction. Using the SJM Epic bioprosthesis in MVR resulted in satisfactory hemodynamics in the early postoperative period, even with small valve sizes. Further accumulation of cases and evidence, including mid- to long-term results, is required in the future.

Clinical outcome of cardiac surgery in patients with remitted or active hepatocellular carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC) is one of the most common primary cancers worldwide. HCC has unique characteristics such as co-existing chronic liver damage and a high recurrence rate. A negative impact on the surgical outcome due to these backgrounds could be expected. We aimed to evaluate the clinical outcomes of cardiac surgery in these patients. METHODS: Between January 2000 and December 2019, 16 patients with remitted cancer and 5 patients with active HCC who underwent open heart surgery were studied. The clinical data were retrospectively evaluated from hospital records. Follow-up information was collected via telephone interviews. RESULTS: The major cause of HCC was viral hepatitis. Eighteen patients (86%) were classified as having Child-Pugh class A cirrhosis. The mean model of end-stage liver disease (MELD) score was 7.2 ± 5.2. There was no 30-day mortality. During follow-up, 11 patients died due to HCC. The 1-, 3-, and 5-year survival rates were 80.0, 42.5, and 22.3%, respectively. A univariate analysis identified a higher preoperative MELD score and lower serum cholinesterase levels as prognostic factors for long-term survival. CONCLUSION: We could safely perform cardiac surgery in selected patients with remitted and active HCC. The postoperative life expectancy of these patients was limited but acceptable.

Minimally invasive cardiac surgery in a patient with osteopetrosis and symptomatic mitral regurgitation.

Osteopetrosis is a rare hereditary bone development disorder caused by osteoclast dysfunction, which increases bone density. Although few studies have investigated cardiovascular disease in osteopetrosis, sternotomy outcomes in this condition are unclear. We report the case of a patient with osteopetrosis and severe mitral regurgitation. A 63-year-old woman with exertional dyspnea had regurgitant systolic murmur audible at the apex. Transthoracic echocardiography showed severe mitral regurgitation due to posterior leaflet prolapse on the anterolateral side. Radiological findings revealed increased bone density (consistent with osteopetrosis). Considering risks in median sternotomy, we performed minimally invasive cardiac surgery through right minithoracotomy for mitral regurgitation. Preoperative imaging showed sclerotic rib changes; nevertheless, sufficient surgical views obtained involved the intercostal space. No residual mitral regurgitation was observed, and the postoperative course was good. To the best of our knowledge, this is the first case report on minimally invasive cardiac surgery for mitral regurgitation with osteopetrosis.