Ring annuloplasty, optionally combined with edge-to-edge leaflet plications, should be amended with subvalvular repair techniques to efficaciously treat tricuspid regurgitation with severe tethering.

OBJECTIVES: This study aimed to evaluate the outcomes of tricuspid annuloplasty with/without additional edge-to-edge plications in patients with functional tricuspid regurgitation (TR) and to clarify the impact of tethering on surgical outcomes. METHODS: This retrospective observational study included patients with moderate or greater functional TR who underwent initial tricuspid valve repair between January 2008 and December 2021. The patients were divided into 2 groups based on whether they had tethering (preoperative tethering area ≥0.75 cm2). All patients underwent annuloplasty, and edge-to-edge plications were added at the regurgitant leakage site identified by saline tests. The surgical outcomes of each group and the effect of tethering on recurrent moderate or greater TR were evaluated. RESULTS: One hundred and thirty-three patients were included in this study. During the follow-up period of 55.3 (standard deviation: 44.9) months, the 5-year survival rates were 78.4% in patients without tethering and 76.1% in patients with tethering (P = 0.78). The 5-year cumulative incidence rates of readmission for heart failure and recurrent TR were 10.8% and 1.3% in patients without tethering and 23.0% and 29.5% in patients with tethering, respectively (P = 0.12 and <0.001). Multivariable analyses revealed that the preoperative and predischarge tethering areas predicted recurrent TR. A large tethering area remained postoperatively in patients with tethering. CONCLUSIONS: In patients without tethering, annuloplasty and additional edge-to-edge plications are effective in avoiding recurrent TR with satisfactory midterm clinical outcomes. However, in patients with tethering, these procedures resulted in residual tethering, which could be leading to recurrent TR.

A prospective randomized controlled study to assess the effectiveness of super FIXSORB WAVE® for sternal stabilization after sternotomy.

BACKGROUND: We developed a new sternal fixation device, Super FIXSORB WAVE®, a corrugated plate made of u-HA/PLLA, to improve sternal stability after sternotomy. This present study aimed to evaluate the new device clinically. METHODS: This prospective, single-blinded, multicenter trial randomized 69 patients to either wire cerclage only (group C, n = 30) or wire cerclage plus Super FIXSORB WAVE® (group W, n = 39). The primary endpoint was a degree of sternal displacement at six months. Displacement of the sternal halves in the anteroposterior and lateral directions was measured using computed tomography horizontal section images at the third costal and fourth intercostal levels. The secondary endpoints were sternal pain and quality-of-life over 6 months. RESULTS: Group W showed significantly reduced sternal anteroposterior displacement at both the third costal (0 [0-1.9] mm vs. 1.1 [0-2.1] mm; P = 0.014) and fourth intercostal (0 [0-1.0] mm) vs. 1.0 [0-1.8] mm; P = 0.015) levels than group C. In group W, lateral displacement was suppressed without a significant increase from 2 weeks to 6 months, while it increased in group C. There was no significant difference in postoperative sternal pain and quality-of-life between the two groups. No adverse events, such as infection, inflammation, or foreign body reaction, were observed with this device. CONCLUSIONS: Using Super FIXSORB WAVE®, sternal displacement was significantly suppressed in both the anteroposterior and lateral directions. The use of this device results in safe and easy sternal reinforcement without any adverse events, and sternal healing can be accelerated. CLINICAL TRIAL REGISTRY NUMBER: This study was registered in the Japan Registry of Clinical Trials (February 21, 2019; jRCTs032180146).

Surgical extraction of cardiac implantable electronic device leads based on a heart team approach.

BACKGROUND: As cardiac implantable electronic devices, such as pacemakers, cardioverter defibrillators, and cardiac resynchronization therapies, have become more popular, device extraction has become more frequent. At our institution, individual treatment strategies are discussed at a heart team meeting. Transvenous lead extraction (TVLE) is a first-line treatment; however, surgical lead extraction (SLE) is sometimes selected as a primary choice to provide optimal treatment and maintain the medical safety policy. This study aimed to investigate the validity of this heart team decision-making. METHODS: From 2013 to 2021, 384 consecutive patients underwent lead extraction at our institution. RESULTS: SLE was proposed as the primary intervention for 21 patients who had high risk of bleeding, difficult TVLE conditions, large vegetations, and other concomitant cardiac diseases. Of the 363 TVLE patients, 10 patients required surgical intervention; 5 had TVLE difficulty followed by SLE and 5 had excessive bleeding. SLE was performed in 26 patients, 19 of whom required valve surgery, and 8 required plication of the great veins. In 4 of the 17 hybrid procedures with SLE and TVLE, excessive bleeding occurred due to laceration of the superior vena cava and innominate vein. Operative mortality was not observed in SLE patients but was observed in 1 of the 4 TVLE patients who required emergent open-chest hemostasis. CONCLUSIONS: The heart team discussion was essential to provide optimal treatment and maintain medical safety policies for each patient. SLE should be selected for patients with high risk of TVLE or other cardiac complications such as tricuspid valve incompetence.

Long-term outcomes of papillary muscle relocation anteriorly for functional mitral regurgitation.

OBJECTIVES: This study aimed to evaluate the outcomes of the patients who underwent restrictive annuloplasty (RA) plus papillary muscle relocation anteriorly (PMR-A) with the risk factors in mitral valve repair for functional mitral regurgitation (FMR). METHODS: Eighty-six patients underwent mitral valve repair with RA for FMR. Thirty-five of them received additional bilateral papillary muscle relocation for severe leaflet tethering. The papillary muscles were relocated posteriorly (PMR-P) early in the study. Then, in the later period, the technique was modified to PMR-A, in which the papillary muscles were relocated anteriorly for 24 cases. The survival of the patients undergoing RA + PMR-A was examined retrospectively, adjusting for differences in patient background. RESULTS: Twenty-three deaths were observed during the follow-up period out of the 86 cases. Independent preoperative risk factors for survival were left ventricular ejection fraction, patient age and B-type natriuretic peptide (BNP) level. Among the patients with BNP <1000 pg/ml, 5-year survival after RA plus PMR-A was 84.7%, while RA alone was 78.6% and RA + PMR-P 57.1%. Cox proportional hazards regression adjusted for the preoperative risk factors showed a significantly higher hazard ratio of RA + PMR-P to RA + PMR-A (12.77, P = 0.011), while the hazard ratio of RA alone to RA + PMR-A was not significantly different. Furthermore, reverse remodelling of the left ventricle was observed for 3 years only in RA + PMR-A. CONCLUSIONS: Long-term survival for patients who underwent RA plus bilateral PMR-A was promising. Patients with significantly higher BNP had lower survival after valve repair for FMR.

Efficacy of singular and composite annular repositioning and subvalvular surgical techniques to treat functional tricuspid regurgitation due to leaflet tethering: Early results of a feasibility study.

OBJECTIVES: The goal of this study was to evaluate the outcomes of patients with subvalvular procedures for functional tricuspid regurgitation (TR) with severe leaflet tethering. METHODS: Of 175 patients who had tricuspid valve surgery between June 2016 and June 2021, a total of 17 patients with functional TR with a preoperative tethering height ≥8 mm underwent subvalvular procedures (annular repositioning [An-Rep]) to reduce septal leaflet tethering, papillary muscle relocation to reduce anterior leaflet tethering, and/or papillary muscle bundling [PMB] to reduce anterior and posterior leaflet tethering along with ring annuloplasty at our institution. A single subvalvular procedure was performed in 9 patients (An-Rep in 5 patients, PMB in 4 patients; group S), and a combination of subvalvular procedures was performed in 8 patients (An-Rep and papillary muscle relocation in 5 patients, An-Rep and PMB in 3 patients; group C). RESULTS: Predischarge TR grades and tethering height were significantly improved (3.2 ± 1.3-1.0 ± 0.5, p = 0.001; 9.9 ± 2.5 mm-5.5 ± 2.8 mm, p < 0.001, respectively). An-Rep and PMB significantly reduced the postoperative closing angles of the septal and anterior leaflets, respectively. During the 20.4 ± 19.5-month follow-up period, the rates of freedom from death and moderate TR at 2 years were 41.7% in group S, and 71.4% in group C (p = 0.39), respectively. In group C, TR recurrence was not observed at 2 years postoperatively. CONCLUSIONS: Subvalvular procedures were effective in reducing the predischarge TR grades and tethering height. The combination of subvalvular procedures might be a durable strategy to prevent recurrent TR.

The rotational position of the aortic valve: implications for valve-sparing aortic root replacement.

OBJECTIVES: There are few reports on the rotational position of the aortic valve relative to the base of the left ventricle, and its influence on valve-sparing aortic root replacement (VSRR) has not been reported. Based on our experience with complications such as right atrial perforation and tricuspid valve injury, we investigated the cause of these complications in terms of morphological variations in the aortic root and its surrounding structures. METHODS: The aortic valve rotation relative to the base of the left ventricle was assessed in 30 patients with tri-leaflet aortic valves who underwent VSRR. The influence of such anatomical variations on surgical procedures was investigated. RESULTS: The aortic valve was positioned normally in 25 patients (83.3%), rotated counterclockwise in 4 (13.3%), and rotated clockwise in 1 patient (3.3%). In patients with a counterclockwise rotated aortic valve, the non-coronary sinus was the largest compared with other sinuses. This aortic valve rotation could be diagnosed by multidetector row computed tomography. In all patients who had difficulty in the external dissection of the right sinus of Valsalva, the aortic valve was counterclockwise rotated and forcible dissection had a risk of right atrial perforation and tricuspid valve injury. CONCLUSIONS: Aortic valve rotation is an element that complicates VSRR. The rotational position of the aortic valve can be diagnosed preoperatively using multidetector row computed tomography and understanding the anatomy of the aortic valve related to rotational position help decide proper surgical decision-making in performing aortic root reconstruction procedure.

Surgical strategy for inflammatory thoracic aortic aneurysms in the endovascular surgery era.

OBJECTIVE: Inflammatory thoracic aortic aneurysms (TAAs) are very rare aortic conditions. Resection and replacement of the inflammatory aorta is the first-line treatment, and thoracic endovascular aortic repair (TEVAR) has recently been reported as a less invasive alternative even for this aortic cohort. In the present study, we reviewed our experience with inflammatory TAAs and assessed the preoperative management, surgical procedures, and outcomes. METHODS: From 2006 to 2019, 21 surgeries were performed for inflammatory TAAs in 17 of 2583 patients (0.7%) who had undergone cardiovascular surgery at our institution. The etiologies were Takayasu's arteritis in 13 patients, giant cell arteritis in 2, antineutrophil cytoplasmic antibody-associated vasculitis in 1, and unknown in 1. The mean follow-up period was 66.2 ± 50.2 months (range, 19-186 months). RESULTS: Three patients had undergone multiple surgeries. The aorta was replaced in 14 patients (ascending aorta in 9, aortic arch in 4, and thoracoabdominal aorta in 1). Three isolated TEVARs were performed in two patients and single-stage hybrid aortic repair (ascending aorta and partial arch replacement combined with zone 0 TEVAR) in four patients for extended arch and descending thoracic aortic aneurysms. Stent grafts were deployed on the native aorta in five of the seven TEVARs. The perioperative inflammation was well-controlled with prednisolone (mean dose, 7.4 ± 9.4 mg) in all patients except for one who had required two surgeries under inflammation-uncontrolled situations. No aorta-related complications, including anastomotic aneurysms and TEVAR-related aortic dissection, developed during the follow-up period, and the 5-year freedom from all-cause death was 92.9%. CONCLUSIONS: The mid-term outcomes of surgery for inflammatory TAAs were acceptable. Although replacement remains the standard procedure for inflammatory TAAs, TEVAR is a less invasive acceptable alternative when the inflammation is properly managed.

One-Stage Hybrid Total Aortic Arch and Descending Thoracic Aortic Repair is a Safe and Secure Procedure With Less Postoperative Complications for Extended Aortic Arch Aneurysms.

PURPOSE: Hybrid aortic arch repair (HAR) has been implemented for extended aortic arch and descending thoracic aortic disease since 2012 in our institution. This study aimed to estimate the early and mid-term efficacy and safety of HAR. MATERIALS AND METHODS: From 2007 to 2019, 56 patients underwent HAR for extended aortic arch disease, and 75 patients underwent total arch replacement (TAR) for arch-limited disease. HAR comprises 3 procedures: replacement of the aorta, reconstruction of all arch vessels, and thoracic endovascular aortic repair (TEVAR) from zone 0 to the descending aorta after cardiopulmonary bypass is off in 1 stage. The type II-1 HAR procedure, in which the ascending aorta and aortic arch distal to the brachiocephalic artery are replaced, was the most frequently selected procedure (40/56 patients). The outcomes of the type II-1 HAR procedure were compared with those of TAR using the Cox regression analysis. RESULTS: The median follow-up period was 36 months. In HAR, the operative mortality, in-hospital mortality, and postoperative permanent neurological deficits were not observed. The paraplegia rate was 1.8%. TEVAR-related complications occurred in 3 patients. Among the patients with non-ruptured atherosclerotic aortic arch aneurysm (31 type II-1 HAR patients and 36 TAR patients, the postoperative respiratory support time in those who underwent type II-1 HAR was quicker than in those who underwent TAR (p<0.01). The rate of 6 year freedom from all-cause death in type II-1 HAR (83.1%) was numerically higher than that in TAR (74.7%), and the rate of 6 year freedom from surgery-related complications in type II-1 HAR (90.3%) was numerically lower than that in TAR (96.9%) due to the occurrence of TEVAR-related complications, and the rate of 6 year freedom from reintervention to the descending thoracic aorta in type II-1 HAR (100%) seemed to be better than that in TAR (83.7%). However, Cox regression analysis did not reveal any statistical difference between the 2 procedures. CONCLUSIONS: HAR, especially the type II-1 procedure, can treat extended aortic arch disease with acceptable survival outcomes. The development of TEVAR technology will further improve the outcomes of HAR in the future.

[Surgical Management for Cardiac and Aortic Lesion Caused by Arteritis].

Arteritis is an inflammatory disease of the vessel walls, resulting in vascular damage and a wide variety of clinical symptoms and multisystem disorders. Because aneurysmal disease, coronary disease, and aortic insufficiency affect patient prognosis, surgical intervention plays an important role. Preoperatively, systemic vessels, cardiac function, and other major organs should be evaluated. Regarding the surgical technique, reinforcement of the anastomosis to the fragile aortic wall is important to prevent pseudoaneurysmal formation and prosthetic valvular detachment. As aortic root replacement, we have been applying the modified Bentall procedure with a "double fixation technique" and obtained desirable outcomes. Although endovascular repair for aneurysmal disease is one of the treatment options, its longterm efficacy remains uncertain. Postoperative control of inflammation with corticosteroids and/or immunosuppressive agents is also important for long-term management. Pseudoaneurysmal formation and prosthetic valvular detachment may occur progressively over a long period of time. To prevent these complications, strict follow-up with imaging and inflammation control should be performed.

Development of a Novel Heart Positioner for Minimally Invasive Coronary Surgery.

PURPOSE: We developed a heart positioner, the Tentacles NEO, specifically designed for minimally invasive coronary artery bypass grafting (MICS-CABG). DESCRIPTION: The device has 3 flexible suction tubes, with a suction cup at the tip of each tube. The suction tubes can be detached from the device body, allowing them to be manipulated in any direction through a small incision around the small thoracotomy. When the device displaces the heart, the suction cup moves behind the chest wall and does not crowd the operative field. EVALUATION: Although the sideways suction force of the new device was as strong as that of the original device, Tentacles, the longitudinal and perpendicular force exerted was approximately 80% of the original device. Nevertheless, the new device could safely and favorably displace the heart in a pig model and even during off-pump CABG via sternotomy. During MICS-CABG, the device was able to displace the heart without crowding the operative field. CONCLUSIONS: The new heart positioner, Tentacles NEO, is a useful and practical heart positioner suitable for MICS-CABG.

Coronary Ostial Patch Angioplasty With Femoral Artery in Takayasu Arteritis.

Takayasu arteritis (TA) occasionally involves the coronary ostium leading to myocardial ischemia. Although surgical coronary ostial angioplasty is desirable for ostial stenosis, the patch materials and long-term results are controversial. We used femoral artery (FA) as a patch material for coronary ostial angioplasty in 3 TA patients. Coronary ostial enlargement with a longitudinal incision followed by rectangular FA patch augmentation was performed to extend the narrowing coronary ostium. In all patients, coronary ostial stenosis was successfully repaired. Ostial angioplasty using an FA patch would be a reasonable surgical strategy to treat coronary ostial stenosis in TA.

Safe and Effective Ultrasound-guided Myectomy and Mitral Valve Repair for HCM.

Surgery for obstructive hypertrophic cardiomyopathy with mitral abnormality requires a combined procedure of myectomy and mitral leaflet plication for relieving mitral systolic anterior motion and left ventricular outflow tract obstruction. We report a combined procedure of myectomy using intracardiac high-resolution ultrasonography and mitral bileaflet shortening in obstructive hypertrophic cardiomyopathy. Stepwise real-time verification of residual ventricular mass using high-resolution ultrasonic probe would be a potent addition to our armamentarium. This modality provides safe and effective myectomy, which has been a most technically challenging surgical procedure especially for inexperienced surgeons.

Surgical Repair of an Arch and Descending Aortic Aneurysm in a Child.

Pediatric thoracic aortic aneurysms are very rare, and almost all patients with such aneurysms have inflammatory or connective tissue diseases. This report describes a case involving 10-year-old girl who had an aortic arch and descending thoracic aortic aneurysm. Preoperative fluorine-18-fluorodeoxyglucose positron emission tomography combined with computed tomography showed an inflammatory lesion corresponding to the aneurysm's location. The ascending aorta, aortic arch, and descending thoracic aorta were replaced through median sternotomy and left thoracotomy with safe systemic and brain perfusion to avoid placing the anastomoses within the inflammatory lesion. The patient was discharged without complications, and an SMAD3 mutation was detected by postoperative mutational screening.

[Salvage from Extracorporeal Membrane Oxygenation due to Acute Deteriorated Heart Failure;Treatment Decision-tree Based on the Risk Factors].

BACKGROUND: Salvage rates for patients requiring extracorporeal membrane oxygenation (ECMO)due to acute cardiogenic shock remain poor due to difficulties in decision making on optical timing of ECMO removal or conversion to ventricular assist devices( VAD). METHOD: From 2005 to 2018, 37 patients supported with ECMO due to acute circulatory deterioration were referred to our department for implantation of VAD. Their outcomes were analyzed using multi-variate analysis to assess the risk factors of VAD implantation, and we adopted a new decision-tree to improve the outcomes. RESULTS: Four patients had severe cerebral complications and 2 patients suffered severe infection. Those 6 patients were withdrawn from VAD implantation. ECMO could be removed in 6 patients, but one of them underwent VAD implantation due to the intraaortic balloon pumping (IABP) -dependent circulatory condition. In total, 25 patients underwent VAD implantation. Four patients reached to heart transplantation. Six patients remain on VAD. VAD was explanted due to recovery in 2 patients. Statistically significant risk factors by multi-variate analysis on 2-year mortality were preoperative necessity of renal replacement (p=0.006) and T-Bil (p=0.051, >4.0 mg/dl). Two-year survival of patients without end-organ dysfunction was 83.3%.However, 2-year survival of patients with end-organ dysfunction was miserable (23.1%). Based on these findings, we applied to a new decision-tree with 4 steps from 2016;(1) rule out strokes and sepsis, (2) End-organ dysfunction should be treated before VAD implantation with proper management of mechanical circulatory support to recover end-organ dysfunction, (3) urgent conversion to VAD if there is no aortic valve opening, (4) conversion to VAD if cardiac functional recovery cannot be observed within 5 to 7 days. According to this decision-tree, 3 patients underwent VAD implantation after recovery from end-organ failure and survived in 2016. CONCLUSIONS: Our experiences of salvage from ECMO in patients with severely impaired cardiac function suggest that end-organ dysfunction( necessity of renal replacement and T-Bil>4.0 mg/dl) was a strong risk factor for mid-term mortality. Those patients should undergo VAD implantation after recovery from end-organ dysfunction.

[Redissection of the Aortic Root Three Months after Replacement of the Ascending Aorta for Acute Stanford Type A Dissection;Report of a Case].

We report a case of redissection of the aortic root after graft replacement for acute aortic dissection using BioGlue to approximate the false lumen. A 49-year-old man underwent graft replacement of the ascending aorta for acute aortic dissection. In this operation, BioGlue was applied to the false lumen of the aortic root. Three months later, computed tomography revealed an ulcer-like projection and an intramural hematoma in the aortic root. Aortic root replacement was performed, in which operative findings showed a new intimal tear and a patent false lumen contained with hematomas and a fragment of BioGlue. Histological examination showed no evidence of adhesion between the intimal media and the adventitia of the aorta, or toxic effect of BioGlue. We conclude that care should be taken in applying the BioGlue to a false lumen and that cautious follow-up is mandatory not to overlook redissection.

Minimally Circulatory-Assisted On-Pump Beating Coronary Artery Bypass Grafting for Patients With Complex Conditions for Off-Pump Surgery.

Off-pump coronary artery bypass grafting (OPCAB) in patients with acute myocardial infarction (AMI) is difficult because of circulatory deterioration during displacement of the heart. At our institution, we performed minimally circulatory-assisted on-pump beating coronary artery bypass grafting (MICAB) in these patients. During MICAB, support flow was controlled at a minimal level to maintain a systemic blood pressure of approximately 100 mm Hg and a pulmonary arterial systolic pressure of <30 mm Hg, providing optimal pulsatile circulation for end-organ perfusion and prevention of heart congestion. From September 2006 to March 2012, MICAB was performed in 37 patients. Either emergent or urgent MICAB was performed in 27 patients following AMI because of hemodynamic instability during reconstruction. Elective MICAB was performed in the remaining 10 patients because of dilated left ventricle (LV) or small target coronary arteries. The details of bypass grafts, perioperative renal function, and early and mid-term morbidity and mortality were compared between the patients who received MICAB and the 37 consecutive patients who underwent OPCAB during the study period at our hospital. The assist flow indices (actual support flow/body surface area) during anastomosis to the left anterior descending artery, left circumflex artery, and right coronary artery were 0.95 ± 0.48 L/min/m2 , 1.32 ± 0.53 L/min/m2 , and 1.15 ± 0.47 L/min/m2 , respectively, in the emergent and urgent patients following AMI, and 0.44 ± 0.39 L/min/m2 , 1.25 ± 0.39 L/min/m2 , and 1.14 ± 0.43 L/min/m2 , respectively, in the elective patients with either dilated LVs or small target vessels. The lowest mixed venous oxygen saturation during pump support in the MICAB group was significantly higher than that in the OPCAB group (83.8 ± 10.8%, 71.6 ± 7.5%, P < 0.001). Comparing MICAB and OPCAB, the median number of distal bypass grafts for both groups was 4 (25th, 75th percentile: 3, 4) (P = 0.558); the complete revascularization rates were 94.6 and 97.3%, respectively (not significant [NS]); the acute patency rates were 98.9 and 99.2%, respectively (NS); and the 30-day mortality rates were 2.7 and 0%, respectively (NS). No instances of either cerebrovascular complications or newly occurring postoperative renal failure were noted in either group. There were no statistically significant differences between the groups with respect to early and mid-term results (freedom from all-cause death: 82.9 vs. 86.5%, respectively, and freedom from cardiac events at 3 years: 96.4 vs. 96.4%, respectively). MICAB is a safe alternative to OPCAB, particularly in patients with AMI and dilated LV. MICAB is associated with high rates of complete revascularization and acute graft patency, adequate preservation of end-organ function, and early and mid-term results comparable with those observed following OPCAB.

[Tricuspid Valve Regurgitation and Right Heart Failure due to Perioperative Right Ventricular Myocardial Infarction].

We herein experienced 2 cases of severe tricuspid valve regurgitation (TR) and right heart failure after mitral valve surgery. In these cases, echocardiography showed a marked right ventricular dilatation and severe TR, which ware suspected to result from a right ventricular myocardial infarction at the time of the 1st operation. We considered the cause of right ventricular infarction to be an air embolism of the right coronary artery or inadequate cardioplegic perfusion to the right ventricle. Since these incidences, we have paid more careful attention to the de-airing of the left ventricle and aortic root and provided more frequent and strict delivery of antegrade and retrograde cardioplegic perfusion. Consequently, we have not since experienced any similar complications at our institute.