Modified composite-graft technique for aortic root replacement.

This report describes a novel modification of a self-assembled composite graft to replace the aortic root and left ventricular outflow tract (LVOT). This technique enables the implantation of a larger valve than conventional ways and simultaneous reconstruction of LVOT. This technique comprises Inspiris Resilia aortic valve and Gelweave Valsalva graft. By placing the valve in the sinus portion of the graft, the bioprosthesis that is 1 mm smaller than the graft can be accommodated, providing a proper length of the collar for LVOT reconstruction. This technique is useful for patients who require redo-aortic root replacement and have restricted LVOT.

Heart Transplantation From DCD Donors in Australia: Lessons Learned From the First 74 Cases.

Heart transplantation from donation after circulatory death (DCD) donors has the potential to substantially increase overall heart transplant activity. The aim of this report is to review the first 8 y of our clinical heart transplant program at St Vincent's Hospital Sydney, to describe how our program has evolved and to report the impact that changes to our retrieval protocols have had on posttransplant outcomes. Since 2014, we have performed 74 DCD heart transplants from DCD donors utilizing a direct procurement protocol followed by normothermic machine perfusion. Changes to our retrieval protocol have resulted in a higher retrieval rate from DCD donors and fewer rejections of DCD hearts during normothermic machine perfusion. Compared with our previously reported early experience in the first 23 transplants, we have observed a significant reduction in the incidence of severe primary graft dysfunction from 35% (8/23) to 8% (4/51) in the subsequent 51 transplant recipients ( P < 0.01). The only withdrawal time interval significantly associated with severe primary graft dysfunction was the asystolic warm ischemic time: 15 (12-17) versus 13 (11-14) min ( P < 0.05). One- and 5-y survival of DCD heart transplant recipients was 94% and 88%, comparable to that of a contemporary cohort of donation after brain death recipients: 87 and 81% ( P -value was not significant). In conclusion, heart transplantation from DCD donors has become a major contributor to our overall transplant activity accounting for almost 30% of all transplants performed by our program in the last 2 y, with similar DCD and donation after brain death outcomes.

Impact of sleep-disordered breathing on ventricular tachyarrhythmias after left ventricular assist device implantation.

Sleep-disordered breathing (SDB) is associated with an increased risk of adverse events in patients with heart failure (HF); however, its impact in patients implanted with a left ventricular assist device (LVAD) remains unclear. We aimed to investigate the prevalence of SDB in patients with LVAD and its impact on their clinical outcomes. Fifty consecutive patients with LVAD who underwent portable sleep monitoring between September 2017 and April 2018 were prospectively enrolled, and they were followed up for 170 ± 36 days. According to their respiratory disturbance indexes (RDIs), they were categorized into the SDB group (RDI ≥ 15, n = 12) and the non-SDB group (RDI < 15, n = 38). The incidence of adverse events during the follow-up period was investigated after enrollment. Multivariate logistic regression analysis revealed significant differences in SDB in LVAD-implanted patients in terms of the logarithmic transformation brain natriuretic peptide (BNP) values (p = 0.005). The optimal BNP cut-off value for SDB prediction in LVAD-implanted patients was 300 pg/mL (sensitivity: 58.3%, specificity: 94.7%). During follow-up, ventricular tachyarrhythmias (VTas) occurred significantly more frequently in the SDB group (4 [33%] vs. 2 [5%] patients, p = 0.02); Atrial tachyarrhythmia (ATa) also tended to occur more frequently in the SDB group (2 [25%] vs. 2 [2%] patients, p = 0.07). SBD was prevalent in 24% of the LVAD-implanted patients with advanced HF. Furthermore, SDB was significantly associated with high BNP levels and was also potentially associated with subsequent incidence of VTa in patients with LVAD.

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

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

Influence of Induction Therapy Using Basiliximab With Delayed Tacrolimus Administration in Heart Transplant Recipients　- Comparison With Standard Tacrolimus-Based Triple Immunosuppression.

BACKGROUND: Appropriate indications and protocols for induction therapy using basiliximab have not been fully established in heart transplant (HTx) recipients. This study elucidated the influence of induction therapy using basiliximab along with delayed tacrolimus (Tac) initiation on the outcomes of high-risk HTx recipients.Methods and Results:A total of 86 HTx recipients treated with Tac-based immunosuppression were retrospectively reviewed. Induction therapy was administered to 46 recipients (53.5%) with impaired renal function, pre-transplant sensitization, and recipient- and donor-related risk factors (Induction group). Tac administration was delayed in the Induction group. Induction group subjects showed a lower cumulative incidence of acute cellular rejection grade ≥1R after propensity score adjustment, but this was not significantly different (hazard ratio [HR]: 0.63, 95% confidence interval [CI]: 0.37-1.08, P=0.093). Renal dysfunction in the Induction group significantly improved 6 months post-transplantation (P=0.029). The cumulative incidence of bacterial or fungal infections was significantly higher in the Induction group (HR: 10.6, 95% CI: 1.28-88.2, P=0.029). CONCLUSIONS: These results suggest that basiliximab-based induction therapy with delayed Tac initiation may suppress mild acute cellular rejection and improve renal function in recipients with renal dysfunction, resulting in its non-inferior outcome, even in high-risk patients, when applied to the appropriate recipients. However, it should be carefully considered in recipients at a high risk of bacterial and fungal infections.

Robotic minimally invasive direct coronary artery bypass for Kawasaki disease.

Case 1: 17-year-old boy developed severe stenosis at the proximal site of the coronary aneurysm in the left anterior descending artery (LAD). Case 2: 16-year-old boy developed severe stenosis at the proximal site of the coronary aneurysm in the LAD. Case 3: 30-year-old woman developed severe stenosis of the distal portion of the coronary aneurysm in the LAD. Minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal thoracic artery harvest was successfully performed without cardiopulmonary bypass in these three young patients with Kawasaki disease. This is the first case report of robot-assisted MIDCAB for Kawasaki disease.

Early postoperative heparinization reduce hemolysis in patients with HeartMate II devices.

Hemolysis is closely related with pump thrombosis and thromboembolic events in patients with continuous flow left ventricular assist devices. We retrospectively investigated the impact of early postoperative heparinization on hemolysis in patients with HeartMate II devices. From April 2013 to August 2017, 83 patients (age 45 ± 12 years; 20 females; body surface area 1.6 ± 0.2 m2) underwent HeartMate II implantation. Postoperative heparinization was started when hemostasis was achieved and continued until full warfarinization. Hemolysis was defined in accordance with the Interagency Registry for Mechanically Assisted Circulatory Support definitions. The average support period was 22 ± 14 months. The 6-, 12-, and 24-month freedoms from hemolysis were 72%, 70%, and 67%, respectively. Pump thrombosis developed in five (6%) patients and four (5%) required pump exchanges. Heparin start time was significantly later in patients with hemolysis (43 ± 23 h after implantation) versus those without (29 ± 14 h after implantation; p = 0.01). Receiver operating characteristic analysis determined the cut-off point of heparin start time as 29 h. The patients were divided into the early group (heparin start time < 29 h; n = 29), and the late group (heparin start time > 29 h; n = 54). The respective 6-, 12-, and 24-month freedoms from hemolysis for the early group (86%, 86%, and 86%, respectively) were significantly higher than those for the late group (49%, 47%, and 44%, respectively; p = 0.002). Being in the late group was an independent risk factor for hemolysis (hazard ratio 4.09). Early postoperative heparinization (within 29 h after implantation) reduces hemolysis in patients with HeartMate II devices.

Multimodality imaging and three-dimensional printed model in patients with left ventricular outflow tract obstruction.

Surgical treatment is an effective therapy and the gold standard for patients with left ventricular outflow tract obstruction (LVOTO) and drug-refractory symptoms. However, it is difficult to arrange a concrete surgical plan due to the heterogenous and complex cardiac anatomy. Three-dimensional (3D) printing is an emerging technology that is able to reproduce complex cardiac anatomy. Here, we present two patients with LVOTO in whom we created 3D printed models. In these two patients, we compared the 3D printed model and the intraoperative findings and confirmed that the 3D printed model we created could reproduce the complex cardiac anatomy including the interventricular septum, papillary muscles, and abnormally thickened chordae. By using 3D printed models, cardiologists and surgeons can comprehend the complex 3D cardiac structure and spatial positional relationship preoperatively and perform surgical rehearsal. 3D printing could be a valuable tool for the management of patients with LVOTO.

Left ventricular assist device implantation in an adult male with Danon disease.

Danon disease is an extremely rare inherited disorder characterized by cardiac involvement, myopathy, and intellectual disability. As patients with Danon disease die at an early age, mainly as a result of cardiac involvement, implantation of a left ventricular assist device (LVAD) and/or heart transplantation are essential options. However, various comorbidities associated with Danon disease should be assessed when these patients are being considered as potential heart transplant candidates. We report the case of an adult male patient with dilated-phase hypertrophic cardiomyopathy secondary to Danon disease, who received an LVAD as a bridge to transplantation. .

Role of Gallium-SPECT-CT in the Management of Patients With Ventricular Assist Device-Specific Percutaneous Driveline Infection.

BACKGROUND: Percutaneous driveline infection is a major complication of left ventricular assist device (LVAD). This study evaluated the role of gallium-67 single-photon emission computed tomography (Ga-SPECT)-CT in LVAD-specific percutaneous driveline infection. METHODS: Thirty-six patients with implantable continuous-flow LVAD, who underwent Ga-SPECT-CT to evaluate percutaneous driveline infections, were enrolled and divided into uptake and no-uptake groups based on tracer concentration uptake on Ga-SPECT-CT. Primary outcomes were surgical intervention and readmission for driveline infection. RESULTS: Twenty-two patients had uptake on Ga-SPECT-CT. No significant differences were noted in patient characteristics, wound appearance, or laboratory results. The prevalence of positive skin culture at the driveline exit site (DLES), and usage and duration of antibiotics did not differ. However, the uptake group had higher 1-year event rates (surgical intervention: 39% vs 0%, P = .019; readmission: 74% vs 6.9%, P = .0016). In addition to positive skin culture at DLES and short duration of antibiotic therapy, uptake on Ga-SPECT-CT was a risk factor for surgical intervention (odds ratio 9.00; P = .018) and readmission (odds ratio 7.86; P = .0051). CONCLUSIONS: Ga-SPECT-CT could be one of the clinical modalities for guiding the treatment of driveline infection in patients with a LVAD.

Type and Size of Implanted Bioprosthetic Valve Rather Than Intraoperative Peak Transprosthetic Valvular Velocity Predict Postoperative Midterm Prosthesis-Patient Mismatch in Patients Undergoing Surgical Aortic Valve Replacement.

OBJECTIVES: High transprosthetic valvular peak velocity (PV) is indicative of prosthesis-patient mismatch (PPM), which exacerbates mortality and morbidity after surgical aortic valve replacement (AVR). During surgical AVR, a high intraoperative PV sometimes is detected, but whether it affects mortality and morbidity is unknown. The aims of this study were to determine whether intraoperative and postoperative PV were correlated and what factors predicted postoperative PPM. DESIGN: Retrospective, observational, cohort study. SETTING: Tertiary medical center. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study comprised 556 patients who underwent AVR with a bioprosthetic valve. PV was measured intraoperatively, 1 month after surgery, and 1 year after surgery. The occurrence of PPM was defined as an effective orifice area index of less than 0.85 cm2/m2. The associations between PV values at the aforementioned 3 time points were analyzed using a multivariable nonlinear regression model. A multivariable logistic regression model was used to identify the predictors of PPM at 1 year. There was no significant association between intraoperative PV and PV at 1 month (p = 0.419) or 1 year (p = 0.115). The implanted valve type (p < 0.001) and size (p < 0.001), but not intraoperative PV (p = 0.503), were independent predictors of PPM. CONCLUSIONS: There was no significant association between intraoperative and postoperative PV values. Implanted valve type and size, but not intraoperative PV, predicted postoperative PPM.

Experience of the use of octreotide for refractory gastrointestinal bleeding in a patient with Jarvik2000® left ventricular assist device.

Gastrointestinal bleeding (GIB) is among the major complications affecting implantable continuous-flow left ventricular assist device (iLVAD) recipients and is the major cause of re-hospitalization. GIB in iLVAD recipients is sometimes critical, and controlling bleeding using conventional approaches is difficult. A 35-year-old woman developed refractory GIB from multiple gastric polyps and de novo angiodysplasia after Jarvik2000® iLVAD implantation. Discontinuation of anticoagulation and antiplatelet therapies had little effect on GIB; thus, multiple endoscopic hemostatic therapies were performed. However, bleeding recurred several times, and red blood cell (RBC) transfusion in large volumes was required for progressive anemia. Furthermore, the von Willebrand factor (VWF) multimer analysis revealed loss of the high-molecular weight multimer, which may have resulted from the high-speed rotation of the axial-flow LVAD pump. To supplement VWF, cryoprecipitate was administered, but it was effective for only several days. Finally, the patient was treated with octreotide, a somatostatin analog, on post-operative day 58. After starting octreotide, tarry stool gradually decreased, and progression of anemia slowed down within the first 14 days of treatment; thus, the total RBC transfusion volume was reduced without additional hemostatic interventions, including cryoprecipitate administration. The patient developed mediastinitis on post-operative day 68 and died of sepsis on post-operative day 72. There was no adverse effect associated with octreotide use. Although the observation period was short, octreotide appears to be useful for resolving recurrent GIB after iLVAD implantation and reducing blood transfusions.

Multiple Coronary Artery Bypass Grafting for Kawasaki Disease-Associated Coronary Artery Disease.

BACKGROUND: Although coronary artery bypass grafting (CABG) is the preferred choice for advanced Kawasaki disease (KD)-associated coronary artery disease, graft design such as number of grafts or type of conduits has not been fully established. We reviewed a series of patients who underwent single or multiple CABG for coronary artery disease of KD sequelae to investigate the optimum revascularization strategy. METHODS: We enrolled a consecutive series of 102 CABG surgeries in 92 patients during the last 36 years. Mean patient age at CABG was 14.9 ± 10.4 years. Internal thoracic artery, radial artery, and gastroepiploic artery were used in 100 (98%), 18 (15%), and 4 (4%) cases, respectively. Patients were divided into 2 groups by single (n = 53) or multiple (n = 49) CABG. RESULTS: Actuarial survival was 93% in single CABG and 91% in multiple CABG at 30 years (P = .71). There was no in-hospital mortality, but 6 deaths occurred long term, with no significant difference between the groups. Freedom from cardiac events was 45.2% in single CABG and 68.5% in multiple CABG at 25 years (P = .228), and reintervention to the left anterior descending (LAD) artery territory was the most common event. Graft patency of the internal thoracic artery-LAD artery graft was 81% in single CABG and 85% in multiple CABG at 25 years. Patency of the radial artery in the non-LAD artery territories was significantly greater than that of the saphenous vein graft at 10 years (91% vs 46%, P = .013). CONCLUSIONS: Multiple CABG using arterial conduits is feasible, safe, and therapeutically effective long term for patients with advanced KD-associated coronary artery disease.

Contemporary outcomes of the concomitant CryoMaze procedure.

OBJECTIVES: As an institutional strategy, the CryoMaze procedure has been established for treating atrial fibrillation (AF) since 2001. In this study, we aimed to analyse the contemporary outcomes of the CryoMaze procedure and to examine the predictive factors of successful sinus rhythm conversion. METHODS: Between January 2009 and March 2018, we performed 352 CryoMaze procedures. The contemporary outcomes of the CryoMaze procedure concomitant with other cardiac procedures were analysed by the Kaplan-Meier method. The logistic regression model was used to predict risk factors for recurrent AF. RESULTS: There were no 30-day or in-hospital deaths and all of the patients were discharged. The 1- and 5-year survival rates were 99.0% and 94.6%, respectively. The rates of freedom from permanent pacemaker implantation and cerebrovascular accidents were 92.6% at 1 year and 86.9% at 5 years, and 99.1% at 1 year and 97.9% at 5 years, respectively. The rates of freedom from recurrent permanent AF were 91.9% at 1 year and 86.1% at 5 years. The multivariable analysis showed that the independent predictive factors for recurrent permanent AF included an F-wave grade in lead V1 (P < 0.001), the preoperative duration of persistent AF (P = 0.031), a non-mitral procedure (P = 0.019) and a preoperative tricuspid regurgitation grade (P = 0.034). CONCLUSIONS: Preoperative voltage of the F wave in V1 lead is strongly associated with the sinus rhythm restoration after the CryoMaze procedure.

Heart Transplantation Ameliorates Ambulation Capacity in Patients With Muscular Dystrophy　- An Analysis of 9 Cases.

BACKGROUND: Heart transplantation (HTx) is reported to have a comparable effect on the prognosis of heart failure patients without muscular disease and for those with muscular dystrophy (MD). However, little is known about the changes in muscular diseases in patients with MD after HTx. Methods and Results: We assessed the ambulatory capacity of 9 patients with MD who underwent HTx. All patients demonstrated improvement in ambulation to varying degrees and 1 patient successfully climbed Mount Fuji 3.8 years after HTx. CONCLUSIONS: HTx potentially improves not only the prognosis but also the ambulatory capacity of patients with MD.

Driveline angle is crucial for preventing driveline infection in patients with HeartMate II device.

We hypothesized that the externalizing direction of the driveline (the driveline angle) at the percutaneous exit site would influence the occurrence of driveline infection after left ventricular assist device implantation. From August 2013 to May 2017, 71 patients were implanted with a HeartMate II device in our center. The driveline angle was measured on anteroposterior radiography just after implantation. Risk factors for driveline infection were analyzed by uni- and multivariate analyses. Driveline infection developed in 10 (14%) patients during follow-up. Overall actual freedoms from driveline infection at 6, 12, and 24 months were 96%, 88%, and 86%, respectively. Overall number of driveline infection events per patient-year was 0.16. Receiver operating characteristic analysis determined the cut-off point of the driveline angle as 41°. The 6-, 12-, and 24-month actuarial freedoms from driveline infection in those with driveline angle more than 42° (84%, 74%, and 74%, respectively) were significantly lower than in those with driveline angle less than 41° (97%, 94%, and 90%, respectively; p < 0.02). The numbers of driveline infection events per patient-year were 0.16 in patients with driveline angle more than 42°, and 0.04 in patients with driveline angle less than 41°. Multivariate analysis demonstrated that driveline angle more than 42° was an independent risk factor for driveline infection (hazard ratio 4.71). Driveline angle more than 42° is an independent risk factor for driveline infection in patients with HeartMate II. Externalization of the driveline toward the horizontal direction is important to prevent driveline infection with HeartMate II.

De novo malignancy in heart transplant recipients: A single center experience in Japan.

BACKGROUND: Because of aggressive immunosuppression, heart transplant recipients have a high risk of de novo malignancy, which is a major cause of death and worse prognosis, regardless of the type. However, the impact of de novo malignancy on Japanese heart transplant recipients is unknown. METHODS: We analyzed 103 Japanese heart transplant recipients over 18-years-old at the time of transplantation between April 1999 and April 2017. Patient characteristics and prognosis were compared between heart transplant recipients with or without de novo malignancy after heart transplantation (HTx). Additionally, univariate and multivariate analyses for the risk factors of de novo malignancy after HTx were performed. RESULTS: De novo malignancy developed in 7 patients (6.8%; post-transplant lymphoproliferative disorders, n=3; Bowen's disease, n=1; colon cancer, n=2; bladder cancer, n=1). Follow-up time and previous antibody mediated rejection (AMR)≥grade 1 were risk factors of de novo malignancy after HTx in multivariate analysis (OR: 1.19, 95% CI: 1.00-1.42, p=0.043; and OR: 10.7, 95% CI: 1.37-83.68, p=0.038, respectively). History of malignancy was a potential risk factor, albeit not significant (OR: 23.05, 95% CI: 0.99-534.53, p=0.071). The survival rates in patients with de novo malignancy was significantly lower than in those without de novo malignancy (3-year survival rate: 100% versus 67%, p=0.0025). CONCLUSIONS: Long follow-up time and previous AMR≥grade 1 were risk factors of de novo malignancy after HTx. Japanese heart transplant recipients with de novo malignancy have worse prognosis; therefore, screening examinations are important for early diagnosis.

Massive Biventricular Myocardial Calcification in a Patient with Fulminant Myocarditis Requiring Ventricular Assist Device Support.

The natural course of myocardial calcification is unclear. We herein report a case of massive biventricular myocardial calcification associated with fulminant myocarditis and present its natural course. The patient was a 15-year-old boy. Massive calcification was detected in both ventricles on computed tomography several months after left ventricular assist device placement. Although the calcification gradually regressed, the patient's cardiac function did not recover, and he underwent heart transplantation after a waiting period of 3 years. A histological examination revealed severe fibrosis in both ventricles of the original heart. Myocardial calcification might suggest severe myocardial inflammation and injury in cases of fulminant myocarditis.

Combined mechanical mitral valve replacement and transmitral myectomy for hypertrophic obstructive cardiomyopathy treatment: An experience of over 20 years.

BACKGROUND: Although transaortic septal myectomy (TASM) is recognized as a standard procedure for treating hypertrophic obstructive cardiomyopathy (HOCM), occasionally the left ventricle (LV) intracavitary gradient remains postoperatively because of this technically demanding procedure. Mitral valve replacement (MVR) is sometimes chosen as an alternative option, but data on its long-term outcomes are lacking. METHODS AND RESULTS: Between 1991 and 2016, 29 patients [age, 14-82 (mean 58.9±15.9) years; 22 female patients (75.9%)] underwent combined mechanical MVR and transmitral myectomy. Of these, six patients had undergone MVR following a second cardiac arrest because of the residual LV outflow gradient or residual mitral regurgitation following TASM. Concomitant TASM was performed in 13 patients. The LV intracavitary gradient at rest assessed by transthoracic echocardiography significantly decreased postoperatively (16.8±19.1mmHg vs. 107.4±52.5mmHg, p<0.0001). Actuarial freedom rates from cardiac death were 92.8%, 89.0%, and 80.1% at 5, 10, and 15 years postoperatively, respectively. Sudden death occurred in three of the four patients who died of late cardiac complications. None of these patients with sudden death had implantable cardioverter-defibrillators. Most patients had maintained their LV end-diastolic dimension at <50mm for 10-15 years postoperatively. Actuarial freedom rates from hospitalization for heart failure were 87.7%, 82.2%, and 54.8% at 5, 10, and 15 years postoperatively, respectively. Occurrence rates of cerebral hemorrhage and infarction were 0.6% per patient-year and 1.3% per patient-year, respectively. CONCLUSIONS: Combined mechanical MVR and myectomy is an effective procedure to eliminate the LV intracavitary gradient in patients with HOCM. Although this procedure remains a viable option in certain situations, optimal medical treatment and close clinical follow-up along with the cooperation between cardiac surgeons and cardiologists are necessary to achieve favorable long-term outcomes.