Inconsistent False Lumen Enhancement Predicts Late Aortic Events After Hemiarch Replacement in Acute Type A Aortic Dissection.

The impact of inconsistent enhancement within the patent false lumen on the occurrence of late aortic events remains uncertain. We enrolled 55patients who exhibited a patent false lumen after hemiarch replacement. The Hounsfield unit (HU) measurements in the patent false lumen were obtained at 2 specific locations: the aortic arch (a) and the descending aorta (b). The false lumen HU score was calculated as the absolute value of 1 - a/b, representing the discrepancy in HUs within the patent false lumen. We investigated the cut-off value of the false lumen HU score with the receiver operating characteristics curve to predict the incidence of late aortic events. We divided the patients based on the cut-off value and compared the cumulative incidence of the late aortic events. The analysis of the receiver operating characteristics curve showed that the cut-off value of the false lumen HU score was 0.345. Based on this cut-off value, we divided them into 2 groups: Group A (score <0.345, n = 26) and Group B (score ≥0.345, n = 29). The baseline characteristics were similar between the 2 groups. The cumulative incidence of the late aortic events was significantly lower in Group A (7.8% at 5 years) than in Group B (39.9% at 5 years) (p = 0.02). The false lumen HU score might be useful to predict the incidence of late aortic events after hemiarch replacement.

Impact of prophylactic donor heart tricuspid valve annuloplasty on outcomes in heart transplantation.

BACKGROUND: Tricuspid regurgitation(TR) following heart transplantation could adversely affect clinical outcomes. In an effort to reduce the incidence of TR, prophylactic donor heart tricuspid valve annuloplasty has been performed during heart transplantation in our institution. We assessed early and long-term outcomes. METHODS: Between August 2011 and August 2021, 349 patients who underwent prophylactic tricuspid valve annuloplasty were included. Tricuspid valve annuloplasty was performed using the DeVega annuloplasty technique. The clinical outcomes of the interests included complete atrioventricular block requiring pacemaker implantation, the occurrence of significant TR(defined as moderate or greater), and survival. Long-term survival was compared in patients with and without significant TR using the Kaplan-Meier method. The Cox proportional hazards regression with time-dependent covariate analysis was used to see if significant TR affected the long-term survival. RESULTS: There was one patient(0.3%) who required pacemaker implantation for complete atrioventricular block. No patients developed tricuspid valve stenosis that required intervention. Significant TR developed in 31 patients(8.9%) during the follow-up period. The survival rate of patients who developed significant TR was significantly lower than that of those who did not(log rank < 0.01). Significant TR was associated with the long-term mortality(HR2.92, 95%CI 1.47-5.82, p < 0.01). CONCLUSIONS: Prophylactic donor heart tricuspid valve annuloplasty has the potential to reduce the occurrence of significant TR and can be performed safely. The significant TR that developed in patients with prophylactic annuloplasty negatively affected survival and was an independent predictor of long-term mortality.

Concomitant left atrial appendage closure during left ventricular assist device surgery can reduce ischaemic cerebrovascular accidents.

OBJECTIVES: It remains unknown if the left atrial appendage closure (LAAC) at the time of left ventricular assist device (LVAD) surgery can reduce ischaemic cerebrovascular accidents. METHODS: Consecutive 310 patients who underwent LVAD surgery with HeartMate II or 3 between January 2012 and November 2021 were included in this study. The cohort was divided into 2 groups: patients with LAAC (group A) and without LAAC (group B). We compared the clinical outcomes including the incidence of cerebrovascular accident between 2 groups. RESULTS: Ninety-eight patients were included in group A, and 212 patients in group B. There were no significant differences between 2 groups in age, preoperative CHADS2 score and history of atrial fibrillation. In-hospital mortality did not differ significantly between the 2 groups (group A: 7.1%, group B: 12.3%, P = 0.16). Thirty-seven patients (11.9%) experienced ischaemic cerebrovascular accident (5 patients in group A and 32 patients in group B). The cumulative incidence from ischaemic cerebrovascular accidents in group A (5.3% at 12 months and 5.3% at 36 months) was significantly lower than that in group B (8.2% at 12 months and 16.8% at 36 months; P = 0.017). In a multivariable competing risk analysis, LAAC was associated with reducing ischaemic cerebrovascular accidents (hazard ratio 0.38, 95% confidence interval 0.15-0.97, P = 0.043). CONCLUSIONS: Concomitant LAAC in LVAD surgery can reduce ischaemic cerebrovascular accidents without increasing perioperative mortality and complications.

Clinical outcomes of grafted vs. percutaneous axillary intra-aortic balloon pump support as a bridge to transplantation: a propensity score-matched analysis.

OBJECTIVES: The purpose of this study is to investigate the early and late outcomes of axillary intra-aortic balloon pump (IABP) implantation as a bridge to heart transplantation, comparing the grafted technique with the percutaneous technique. METHODS: Between July 2009 and January 2020, 163 patients underwent an axillary IABP insertion as a bridge to heart transplantation. Among them, 97 patients underwent axillary IABP implantation through a graft sutured onto the axillary artery (Group A) and 66 patients underwent percutaneously (Group B). Propensity matching identified 53 matched pairs for analysis (C-statistics 0.741). The primary outcomes of interest included IABP-related complications, success rate of a bridge to transplantation, in-hospital mortality, and late survival. RESULTS: In the propensity-score matched cohort, there were no significant differences in the baseline characteristics between the two groups. The operation time was significantly longer in Group A than in Group B (141.5 ± 38.3 min vs 42.7 ± 19.3 min, p < 0.01). The complication rates including stroke, re-exploration for bleeding, and aortic event were not significantly different between Group A and B. However, Group A required more transfusion and re-exploration for bleeding. The success rate of a bridge to transplantation was similar between Group A (47/53, 88.7%) and Group B (47/53, 88.7%). There were no significant differences in in-hospital mortality and late survival between two groups. CONCLUSION: In the propensity score matching analysis, there were not any significant differences between the two groups in IABP-related complications, in-hospital mortality, and late survival. The percutaneous technique provided a shorter operation time and less requirement of transfusion and re-exploration for bleeding compared to the grafted technique. The percutaneous technique might be favorable when feasible.

Alleviation of cognitive deficits via upregulation of chondroitin sulfate biosynthesis by lignan sesamin in a mouse model of neuroinflammation.

Lignans are plant-derived compounds that act as partial estrogen agonists. Chondroitin sulfate proteoglycans (CSPGs) represent one of the major components of the extracellular matrix. Here we aimed to understand the role of sesamin (SES), a major lignan compound, in the biosynthesis and degradation of CSPGs in the mouse hippocampus because CSPGs play a key role in the regulation of cognitive functions through the promotion of adult neurogenesis. The expression of the pro-inflammatory cytokine interleukin-1ß was decreased by SES administration in the hippocampus of lipopolysaccharide (LPS)-treated mice, a model of neuroinflammation-induced cognitive deficits. The expression of genes related to biosynthesis and degradation of CSPGs in the hippocampus of LPS-treated mice was both increased and decreased by SES administration. Further, the diffuse extracellular matrix labeling of CSPGs by Wisteria floribunda agglutinin (WFA) in the hippocampus of LPS-treated mice was increased by SES administration. The densities of neural stem cells, late transit-amplifying cells, and newborn-granule cells in the hippocampus of LPS-treated mice were also increased by SES administration. Moreover, SES-induced alterations in gene expression, WFA labeling, and adult neurogenesis in LPS-treated mice were more evident in the dorsal hippocampus (center of cognition) than in the ventral hippocampus (center of emotion). Neither LPS nor SES administration affected locomotor activity, anxiety-like behavior, and depression-related behavior. However, impairments in contextual memory and sensorimotor gating in LPS-treated mice were recovered by SES administration. Our results show that SES can promote adult hippocampal neurogenesis through the upregulation of CSPGs, which may alleviate cognitive deficits induced by neuroinflammation.

Comparing short-term/long-term outcomes of heart transplants that occur inside and outside of normal working hours.

AIMS: Heart transplantation involves many factors such as donor selection, recipient management, multidisciplinary assessment, coordination with other organ teams, and transportation. Because of some unpredictable factors, heart transplantation can be conducted at any time of day. The purpose of this study is to investigate if outcomes differ between heart transplants taking place inside or outside of normal working hours. METHODS AND RESULTS: We reviewed patients who underwent heart transplantation at our institution from January 2010 to July 2020 (n = 329). Based on the documented start time of the recipient surgeries, the cohort was divided into two groups: working hours (Group A: 7:30 to 17:00; n = 92) and after hours (Group B: 17:00 to 7:30; n = 237). We compared these groups using propensity score matching analysis. After propensity score matching, 78 pairs of patients were successfully matched. We reviewed early and late clinical outcomes including survival. Long-term survival was compared using the Kaplan-Meier method. In the propensity-score matched patients, there were no significant differences in the baseline characteristics between two groups. In-hospital mortality was not significantly different between the two groups (Group A: 6.4% vs. Group B: 2.6%, P = 0.44). Ischaemic time and cross-clamp time did not differ between the groups. In terms of postoperative complications, there were no significant differences between two groups in stroke (6.4% vs. 3.9%, P = 0.72), primary graft dysfunction requiring extracorporeal membrane oxygenation (5.1% vs. 7.7%, P = 0.75), re-exploration for bleeding (9.0% vs. 12.8%, P = 0.44), and newly required haemodialysis (7.7% vs. 6.4%, P = 0.75). The survival rate in Group A (88.1% at 1 year, 81.3% at 3 years) was not significantly different from Group B (90.5% at 1 year, 82.3% at 3 years, log rank = 0.96). CONCLUSION: There was no significant difference in clinical outcomes between heart transplants taking place inside or outside of working hours. A high quality of care can be provided for heart transplant patients even during after hours.

Surgical Correction of Spontaneous Outflow Graft Twisting of HeartMate 3 LVAD via a Subcostal Approach.

We present two cases of successful surgical correction of a HeartMate 3 left ventricular assist device (LVAD) outflow graft twisting through a subcostal approach. These twistings were diagnosed with computed tomography or pull-back pressure measurement. Technically, a subcostal approach allowed us to access directly the twisted outflow graft and the device connector in a less invasive fashion as compared with a re-sternotomy. Diagnostic modality and surgical tips that address graft twisting are presented within the discussion of these two case studies. The institutional review board of our institution approved this study and waived the requirement for informed consent.

Implications of Heart Rate in Patients with Left Ventricular Assist Devices.

Optimal heart rate (HR) is a promising therapeutic target in patients with heart failure with reduced ejection fraction. Nevertheless, the implication of optimal HR in patients with left ventricular assist devices (LVAD) remains unknown. The cohort included consecutive patients with sinus rhythm undergoing LVAD implantation between 2014 and 2018. Ideal HR was calculated as follows: 93 - 0.13 × (deceleration time [msec]). The impact of "HR difference," defined as an HR difference between the actual HR at discharge and the calculated ideal HR, on the 1-year mortality and heart failure readmissions was investigated. A total of 143 patients (55 years old, 101 men) was identified and tertiled considering their HR differences: (1) the optimal HR group (n = 49; HR difference < 27 bpm), (2) the suboptimal HR group (n = 47; HR difference = 27-42 bpm), and (3) the nonoptimal HR group; HR difference (n = 47; HR difference > 43 bpm). The nonoptimal HR group had a significantly higher 1-year cumulative incidence of the primary endpoint compared with the optimal HR group (38% versus 16%, P = 0.029) with a hazard ratio of 1.69 (95% confidence interval 1.02-2.57) adjusted for 6 potential confounders. In conclusion, nonoptimized HR negatively affected clinical outcomes in LVAD patients. The implication of deceleration time-guided HR optimization in LVAD patients should be further investigated.

Significant vascular complications in percutaneous axillary intra-aortic balloon pump.

OBJECTIVE: Axillary Intra-aortic balloon pump (IABP) has been increasingly utilized for hemodynamic support in heart failure patients. Vascular complications associated with axillary IABP such as dissection or rupture are relatively rare but not negligible that could negatively affect clinical outcomes. We summarized our experiences. METHODS: This is a retrospective study reviewing of all patients receiving an axillary IABP between June 2016 and November 2020. A total of 199 patients underwent percutaneous axillary IABP placement. 6 patients (6/199, 3.0%) were complicated with arterial/aortic dissection or rupture during the procedures or the course of treatment. We described their clinical presentations and outcomes. RESULTS: Vascular complications included acute type A aortic dissection in 2 patients, descending aortic rupture in 1 patient, abdominal aortic rupture along with type B aortic dissection in 1 patient, and the localized left subclavian artery dissection in 2 patient. 2 type A aortic dissection cases were surgically treated: 1 with emergent left ventricle assist device and ascending aorta replacement, the other with emergent left ventricle assist device. Emergent endovascular treatment was successfully performed in 2 aortic rupture cases. The left subclavian artery dissection cases were managed medically. The postoperative/treatment course was uneventful in all patients. CONCLUSION: Percutaneous axillary IABP therapy can cause significant vascular complications. Early diagnosis and prompt treatment would be the key to improve the clinical outcomesv.

Proximal ascending aorta size is associated with the incidence of de novo aortic insufficiency with left ventricular assist device.

We sought to assess the impact of the aortic root geometry on developing de novo aortic insufficiency (AI) in patients undergoing left ventricular assist device (LVAD). In total, 114 patients underwent LVAD implantation between February 2016 and January 2020 were included in this study (HeartMate3 N = 68, HeartWare N = 46). Significant aortic insufficiency was defined as mild-to-moderate or greater in echocardiography. The cohort was divided into two groups; those who developed significant AI (Group AI: n = 13) and did not (Group non-AI: n = 101). The primary outcomes of interest included late survival and predictors for significant AI. The patients in Group AI were older than Group non-AI (62.6 ± 11.9 vs 51.3 ± 14.0 years, p < 0.01). The diameter of proximal ascending aorta in Group AI was larger than Group non-AI (31.0 ± 5.0 vs 27.4 ± 4.3 mm, p < 0.01). Aortic valve remained closed in 53.8% in Group AI and 36.6% in Group non-AI (p = 0.24). The late survival was not significantly different between the groups (67.1% vs 76.0% at 3 years, log rank = 0.97). The Cox hazard model showed that larger proximal ascending aortic diameter/BSA (HR 1.55, CI 1.19-2.04, p < 0.01) and not-opening aortic valve (HR 4.73, CI 1.43-16.9, p = 0.01) were independent risk factors for significant AI. The cutoff value of proximal ascending aortic diameter/BSA was 15.5 (area under curve: 0.770, sensitivity: 0.69, specificity: 0.79). Dilated proximal ascending aorta at the time of LVAD surgery and not-opening aortic valve during follow-up were associated with the incidence of de novo significant AI.

Ten-year, single center experience of ambulatory axillary intra-aortic balloon pump support for heart failure.

BACKGROUND: The axillary intra-aortic balloon pump has an advantage over the femoral intra-aortic balloon pump in terms of mobility. While axillary intra-aortic balloon pump has been widely used recently as a mode of mechanical circulatory support, the number of reported cases is limited. The purpose of this study is to summarize our experience and to evaluate the safety and efficacy of axillary intra-aortic balloon pump support. METHODS: Between July 2009 and July 2019, 241 patients underwent axillary intra-aortic balloon pump support for heart failure. The intended therapeutic goals were bridge to heart transplantation (n=146), left ventricular assist device (n=66), and recovery (n=29). Intra-aortic balloon pumps were inserted through a graft sutured onto the axillary artery in 142 patients (58.9%) and percutaneously in 99 patients (41.1%). It was placed from the right axillary artery in 147 patients (61.0%) and left in 94 patients (39.0%). Primary outcome measures of interest included achievement of intended therapeutic goal, hemodynamic data, ambulatory data, intra-aortic balloon pump-related death, and complications. RESULTS: Ambulation was possible in 217 patients (90.0%) during support. Hemodynamic parameters improved significantly after axillary intra-aortic balloon pump support. In total, 13 patients (5.4%) died and 10 patients (4.1%) required escalation of mechanical support. There were no deaths directly attributable to intra-aortic balloon pumps. Intra-aortic balloon pump-related stroke occurred in 6 patients (2.5%). Overall, 86.7% were successfully bridged to intended therapy (transplantation 90.4%, left ventricular assist device 90.9%, and recovery 58.6%). CONCLUSIONS: Axillary intra-aortic balloon pumps allow most patients to ambulate during support, improve hemodynamics, and lead to the intended goals successfully.

A proposed redosing interval of del Nido cardioplegia solution in adult cardiac surgery: a propensity-matched study.

BACKGROUND: Recently, del Nido cardioplegia solution (DN) has been utilized in adult cardiac surgery. However, adequate interval of maintenance dose(s) is still unclear. The purpose of this study was to assess the safety and efficacy of our DN protocol by comparing with conventional cold whole blood cardioplegia (CWB). METHODS: A total of 1003 consecutive patients (DN group, N = 350 vs. CWB group, N = 653) underwent cardiovascular surgery between July 2013 and September 2018 were included in this study. The DN protocol was to administer 1000 to 1200 ml as an initial dose and to add maintenance dose(s) (500 ml each) every 60 minutes when the estimated cross-clamp time was over 90 minutes. CWB was given every 20 minutes, regardless of cross-clamp time. Propensity matching identified 254 matched pairs for analysis. The preoperative and postoperative data were reviewed. RESULTS: Cross-clamp time was significantly shorter in the DN group compared with the CWB group (107 ± 56 minutes vs. 116 ± 49 minutes, p = 0.0458). A retrograde cannula was used in 124 (48.8%) patients in the DN group and 181 (71.3%) patients in the CWB group (p < 0.0001). There were no significant differences in requiring postoperative cardiac supports (inotropes, mechanical circulatory supports) and major complications. In-hospital mortality was similar between two groups (DN group: 3.2% vs. CWB group: 2.4%, p = 0.5872). CONCLUSIONS: Short-term clinical outcomes in the patients underwent cardiovascular surgery with the DN protocol including the redosing interval strategy were acceptable. Also, DN protocol was associated with shortened cross-clamp time and less usage of the retrograde cannula.

Outcomes of Ambulatory Axillary Intraaortic Balloon Pump as a Bridge to Heart Transplantation.

BACKGROUND: The axillary intraaortic balloon pump (IABP) is frequently used in selected patients for circulatory support as a bridge to heart transplantation. The purpose of this study was to investigate the safety and efficacy of axillary intraaortic balloon pump (IABP) support for heart transplant candidates. METHODS: The study investigators collected data on 133 patients who underwent axillary IABP support as a bridge to transplantation from July 2009 to April 2019. Of these patients, 94 (70.7%) underwent IABP insertion with surgical axillary grafts, and 39 (29.3%) underwent percutaneous IABP insertion. The outcomes of interest included ambulatory data, IABP-related complications, and successful heart transplantation with this type of support. RESULTS: The overall preoperative ejection fraction was 20.3% ± 8.0%. The median duration of axillary IABP support was 21days, with 131patients (98.5%) mobilizing with the device. Hemodynamic variables significantly improved after the axillary IABP support was placed. Overall, 122 patients (91.7%) were successfully bridged to heart transplantation. Six patients (4.5%) required escalation to further mechanical support. Two patients (1.5%) died while awaiting transplantation. Four patients (3.0%) experienced a stroke during axillary IABP support (3 before transplantation and1 after transplantation). Two of the 3 patients with a stroke diagnosis before transplantation recovered and eventually underwent heart transplantation. CONCLUSIONS: With axillary IABP support, most patients were able to ambulate and undergo physical rehabilitation while waiting for heart transplantation. This study demonstrates that axillary IABP results in a high success rate of bridge to transplantation and a low number of complications. Thus, an ambulatory axillary IABP provided efficient and safe support for selected patients as a bridge to heart transplantation.

Orthotopic heart transplantation with persistent left superior vena cava draining into coronary sinus: the anterior rerouting technique.

BACKGROUND: We present a surgical technique for a reconstruction of a persistent left superior vena cava draining into the coronary sinus with orthotopic heart transplantation. METHODS: Between January 2013 and July 2019, a total of 224 patients underwent orthotopic heart transplantation in our institution. Among them, three patients (3/224, 1.3%) had a persistent left superior vena cava draining into the coronary sinus. The persistent left superior vena cava and the coronary sinus was isolated and fully mobilized as an en bloc conduit at the time of explanting the heart. After the standard anastomoses using the bicaval technique, the conduit was routed anterior to the great vessels and anastomosed to the right atrial appendage. A smooth venous drainage into the right atrium from the rerouted persistent left superior vena cava was intraoperatively confirmed by transesophageal echocardiography. RESULTS: The postoperative course was uneventful in all patients. There were no major postoperative complication and in-hospital mortality. The routed persistent left superior vena cava-coronary sinus conduits were confirmed to be patent without stenosis/obstruction by an enhanced computed tomography. Cardiac biopsies through the reconstructed persistent left superior vena cava were possible without any difficulty. CONCLUSION: The anterior rerouting technique for a reconstruction of a persistent left superior vena cava draining into the coronary sinus in an orthotopic heart transplantation was feasible and reproducible.

Successful endovascular repair of aortic rupture caused by axillary intra-aortic balloon insertion for a Jehovah's Witness patient with situs inversus anomaly.

We report the successful endovascular repair of a rare case of aortic rupture caused by axillary intra-aortic balloon pump (IABP) insertion failure. A 38-year-old Jehovah's Witness female with situs inversus totalis was referred to our hospital for acute decompensated heart failure. We placed an axillary IABP for circulatory support. However, an exchange was required due to balloon malfunction (kinked driveline). Unfortunately, the exchange was complicated by an iatrogenic aortic rupture along with a large hematoma compressing the trachea. Emergent endovascular repair was performed successfully without any blood transfusion. Postoperative computed tomography showed a successfully repaired aorta and resolving hematoma.