Quantitative flow ratio versus fractional flow reserve for Heart Team decision-making in multivessel disease: the randomised, multicentre DECISION QFR trial.

BACKGROUND: Vessel-level physiological data derived from pressure wire measurements are one of the important determinant factors in the optimal revascularisation strategy for patients with multivessel disease (MVD). However, these may result in complications and a prolonged procedure time. AIMS: The feasibility of using the quantitative flow ratio (QFR), an angiography-derived fractional flow reserve (FFR), in Heart Team discussions to determine the optimal revascularisation strategy for patients with MVD was investigated. METHODS: Two Heart Teams were randomly assigned either QFR- or FFR-based data of the included patients. They then discussed the optimal revascularisation mode (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) for each patient and made treatment recommendations. The primary endpoint of the trial was the level of agreement between the treatment recommendations of both teams as assessed using Cohen's kappa. RESULTS: The trial included 248 patients with MVD from 10 study sites. Cohen's kappa in the recommended revascularisation modes between the QFR and FFR approaches was 0.73 [95% confidence interval {CI} : 0.62-0.83]. As for the revascularisation planning, agreements in the target vessels for PCI and CABG were substantial for both revascularisation modes (Cohen's kappa=0.72 [95% CI: 0.66-0.78] and 0.72 [95% CI: 0.66-0.78], respectively). The team assigned to the QFR approach provided consistent recommended revascularisation modes even after being made aware of the FFR data (Cohen's kappa=0.95 [95% CI:0.90-1.00]). CONCLUSIONS: QFR provided feasible physiological data in Heart Team discussions to determine the optimal revascularisation strategy for MVD. The QFR and FFR approaches agreed substantially in terms of treatment recommendations.

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.

A Novel Technique of No-Touch Endoscopic Saphenous Vein Harvesting.

No-touch saphenous vein harvesting is considered an ideal procedure for harvesting good-quality veins, whereas endoscopic vein harvesting (EVH) is considered ideal for decreasing wound complications. The no-touch EVH (NT-EVH) technique, which was developed in 2018, is one of the best vein-harvesting procedures. We have improved this method in several aspects since our initial experience. Herein, we present the details of this technique.

BioGlue cerebral embolism following acute type A aortic dissection repair.

Surgical outcomes of acute Stanford type A aortic dissection (ATAAD) have significantly improved in recent decades due to advances in surgical techniques and adhesives such as BioGlue (Cryolife, Kennesaw, GA, USA). However, this convenient material can sometimes cause complications such as thrombotic embolism and pseudoaneurysm. Herein, we present the case of a 61-year-old man with ATAAD who successfully underwent total arch replacement. Five days after surgery, he collapsed due to right-sided hemiplegia. We immediately performed cerebral thrombectomy to remove thrombotic embolism caused by BioGlue, which was used to obliterate the false lumen of the dissected aorta during ATAAD repair. Learning objective: Thanks to surgical techniques and adhesives such as BioGlue, surgical outcomes of acute Stanford type A aortic dissection have significantly improved recently. However, thromboembolic events due to adhesives such as BioGlue use can happen not only during surgery, but also a few days after it.

Aortic dissection due to primary aldosteronism in a young adult with adrenal adenoma: A case report.

Although acute type A aortic dissection is relatively rare in young adults, patients with connective tissue diseases are at a higher risk for developing this condition. To the best of our knowledge, type A aortic dissection due to endocrine diseases has been rarely reported. Here, we present a case of acute type A aortic dissection due to primary aldosteronism in a young man with adrenal adenoma. Total arch replacement was successfully performed. Postoperative imaging and endocrine evaluation revealed an adrenal adenoma. This study highlights the importance of considering primary aldosteronism as a potential etiology of acute aortic dissection in young adults. Learning objective: Generally, direct or indirect causes of acute type A aortic dissection (ATAAD) are highly diversified. We tend to suspect the familial aortic diseases such as Marfan syndrome when patients with ATAAD are young adults. By contrast, it is useful to know that endocrine diseases such as primary aldosteronism with functional adenoma can be risk factors of ATAAD in young adults.

Heart Team risk assessment with angiography-derived fractional flow reserve determining the optimal revascularization strategy in patients with multivessel disease: Trial design and rationale for the DECISION QFR randomized trial.

In patients with multivessel disease (MVD), functional information on lesions improves the prognostic capability of the SYNTAX score. Quantitative flow ratio (QFR®) is an angiography-derived fractional flow reserve (FFR) that does not require a pressure wire or pharmacological hyperemia. We aimed to investigate the feasibility of QFR-based patient information in Heart Teams' discussions to determine the optimal revascularization strategy for patients with MVD. We hypothesized that there is an acceptable agreement between treatment recommendations based on the QFR approach and recommendation based on the FFR approach. The DECISION QFR study is a prospective, multicenter, randomized controlled trial that will include patients with MVD who require revascularization. Two Heart Teams comprising cardiologists and cardiac surgeons will be randomized to select a revascularization strategy (percutaneous coronary intervention or coronary artery bypass graft) according to patient information either based on QFR or on FFR. All 260 patients will be assessed by both teams with reference to the anatomical and functional SYNTAX score/SYNTAX score II 2020 derived from the allocated physiological index (QFR or FFR). The primary endpoint of the trial is the level of agreement between the treatment recommendations of both teams, assessed using Cohen's κ. As of March 2022, the patient enrollment has been completed and 230 patients have been discussed in both Heart Teams. The current trial will indicate the usefulness of QFR, which enables a wireless multivessel physiological interrogation, in the discussions of Heart Teams to determine the optimal revascularization strategy for MVD.

Emergency aortic valve replacement complicated by unmanaged pheochromocytoma.

A 53-year-old male undergoing emergency aortic valve replacement for infective endocarditis developed a hypertensive crisis early during the operation. Suspecting a pheochromocytoma, intravenous phentolamine was immediately administered, after which the procedure was completed as scheduled. Although quite rare, a pheochromocytoma can be encountered during emergency open heart surgery; thus, early recognition of abnormal blood pressure change and appropriate management are important. Here, we present details of blood pressure control mainly by use of phentolamine, in this case, to demonstrate effective management of a hypertensive crisis during emergency cardiac surgery because of a pheochromocytoma.

Giant biatrial myxoma in an atrial septal defect.

Myxomas account for a majority of the reported primary cardiac tumors that are relatively rare, and biatrial myxomas in an atrial septal defect are extremely rare. Here, we present the case of a healthy 79-year-old woman who was referred to our hospital after a giant mass in the left atrium was incidentally detected by transthoracic echocardiography. Although she was asymptomatic, we surgically resected the mass soon after admission, considering the risk of embolism. During the surgery, we observed the giant bilateral tumor in an atrial septal defect, which was, on pathological evaluation, found to be a myxoma. .

A Novel Technique of Endoscopic Vein Harvesting With Preserved Perivascular Tissue.

The no-touch saphenous vein harvesting technique is considered to be the ideal procedure to achieve the best quality of vein, whereas the endoscopic vein harvesting (EVH) technique is considered to be ideal for decreasing wound complications. We developed a new technique of EVH with perivascular tissue preservation. This procedure was performed by dissecting the immediate anterior and posterior perivascular connective tissues of the saphenous vein followed by cutting approximately 1 cm laterally from the saphenous vein with the use of a harvester (MAQUET Getinge Group, Getinge AB, Göteborg, Sweden). Histopathological examination revealed preserved perivascular tissue and intimal folding.