Procedural selection strategy and clinical outcomes in mitral valve surgery with concomitant aortic valve replacement in elderly patients.

Introduction: In the context of double-valve surgery for elderly high-risk patients involving both the aortic and mitral valves, a clinically significant problem has been that no clear criteria or surgical strategies have been reported for the selection of mitral valve plasty (MVP) or mitral valve replacement (MVR) for mitral valve disease management during surgical aortic valve replacement (SAVR) to achieve better clinical outcomes. This study investigated valve durability and survival using our surgical strategy for mitral valve disease with concomitant SAVR in elderly patients. Methods: Eighty-six patients aged > 65 years (mean 75 years) who underwent a double-valve procedure for mitral valve surgery with concomitant SAVR from 2010 to 2022 were reviewed. Our surgical strategy for mitral valve disease with concomitant SAVR for the elderly patients was as follows: MVP was selected for patients in whom mitral valve disease was expected to be controlled with simple surgical procedures (n = 47), otherwise MVR was selected (n = 39). Results: The hospital mortality rate was 8% (n = 7). The mean follow-up was 4.9 (0-12.3) years. And the 10-year survival rate was 62%. The 10-year freedom from aortic valve reoperation rate was 95%. No mitral valve reintervention was performed during follow-up. Echocardiographic follow-up demonstrated freedom from at least moderate mitral regurgitation in 86% of cases at 10 years. Conclusion: In double-valve surgery for elderly high-risk patients, appropriate selection of the mitral valve procedure with concomitant SAVR provided better early and long-term survival and valve durability. This surgical strategy may be beneficial in elderly patients with combined aortic and mitral valve disease.

The Efficacy of Second-Stage Endovascular Repair Strategy for Acute Type A Aortic Dissection.

PURPOSE: To evaluate the usefulness of a hybrid treatment strategy for acute type A aortic dissection (AAAD). METHODS: We retrospectively evaluated the outcomes of 39 partial arch replacements (PAR; 26 male/13 female, mean age=67.9 years) in 62 patients with AAAD operated at our hospital from January 2019 to January 2023. The technique included PAR with graft-designed landing length and translocated the brachiocephalic artery inflow site during the initial surgery to minimize the invasiveness of the surgery. Thereafter, second-stage thoracic endovascular aortic repair (second TEVAR) for distal aortic events in the chronic phase was performed. RESULTS: There was 1 case of 30-day mortality (2.6%) and 2 cases of postprocedural cerebral infarction (5.1%). The cumulative survival rates were 97.4%/1 year and 97.4%/3 years. The cumulative freedom from aorta-related second-stage procedure for the distal aortic event after initial PAR, which was performed in 13 patients (33.3%), was 63.9%/1 year and 59.7%/3 years. All patients requiring re-intervention after initial PAR underwent a second TEVAR with a 100% success rate and no postoperative complications. CONCLUSION: Initial PAR for AAAD in anticipation of the second TEVAR is a valuable strategy for enabling minimally invasive additional treatment of aorta-related re-intervention for distal aortic events in the chronic phase. CLINICAL IMPACT: This study provides detailed information on the hybrid aortic repair strategy of the initial open partial arch repair and second staged endovascular repair for the acute type A aortic dissection. Based on this study, distal aortic re-intervention after initial open partial arch repair was necessary only in about 30% of cases, and no cases of SCI were observed in the initial treatment or in the second-stage endovascular repair and no cases of distal SINE were observed after the second staged endovascular repair. Overall, the results suggest that limiting the initial open partial arch repair can achieve good perioperative and early outcomes of initial surgery, and that second staged endovascular re-intervention for distal aortic events can be performed reliably, safely, and with minimal invasiveness.

Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy.

Objective: In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. Methods: We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. Results: The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. Conclusions: In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.

Aortic thrombosis with visceral malperfusion during circulatory support with a combination of Impella and extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used to aid myocardial recovery in patients with postcardiotomy cardiogenic shock (PCCS), it has been associated with adverse effects. The combined use of VA-ECMO and Impella (ECPELLA) for PCCS, however, has been reported to be efficacious with few reports of thromboembolic events. We present a case of aortic thrombosis with visceral malperfusion during ECPELLA management for PCCS. We performed the Bentall procedure, mitral valve repair, tricuspid annuloplasty, and coronary artery bypass graft on a 73-year-old man admitted with congestive heart failure caused by annuloaortic ectasia, along with severe aortic and mitral regurgitation. VA-ECMO and Impella were required, since the cardiopulmonary bypass weaning was difficult. Impella was removed on postoperative day 4. On postoperative days 5 and 6, laboratory data showed worsening renal dysfunction, lactate levels, and acidosis. Contrast-enhanced computed tomography showed thrombosis in the celiac and superior mesenteric arteries. Aortic thrombectomy was performed. Hyperkalemia, caused by a reperfusion injury, resulted in ventricular fibrillation. Continuous hemodiafiltration improved the hyperkalemia. However, irreversible acidosis progressed, and the VA-ECMO flow rate could not be sustained. On postoperative day 7, the patient died. Perioperative use of Impella for PCCS may be effective in improving postoperative cardiac function. When sudden organ failure is observed after surgery, it is necessary to not only keep the exacerbation of cardiogenic shock in mind, but also the possibility of thrombosis.

Total arch and descending thoracic aortic replacement for massive hemoptysis requiring CPR caused by intrapulmonary penetration of chronic dissecting aortic aneurysm: a case report.

BACKGROUND: Intrapulmonary penetration of the thoracic aorta is a rare, life-threatening complication of a chronic dissecting aortic aneurysm. It causes massive hemoptysis requiring prompt intervention to prevent fatal airway bleeding. A surgical approach that enables diverse surgical maneuvers and intraoperative organ protection is crucial. CASE PRESENTATION: A 62-year-old man, who underwent graft replacement of the ascending aorta for an acute type A aortic dissection 20 months before, developed massive hemoptysis and cardiac arrest. The hemoptysis was secondary to an aortopulmonary fistula from a rapidly expanding dissecting aortic aneurysm. However, a successful return of spontaneous circulation was achieved with cardiopulmonary resuscitation, including establishment of veno-arterial extracorporeal membrane oxygenation. The patient successfully underwent a total arch and descending thoracic aortic replacement. This was achieved by a median sternotomy combined with a left thoracotomy using a straight incision with a rib-cross (SIRC) approach. The patient was uneventfully discharged and remained well for the following 2 years. CONCLUSIONS: When performing a surgical graft replacement for an aortopulmonary fistula with a thoracic aortic aneurysm, the surgical approach chosen is critical. A surgical procedure using a median sternotomy combined with a left thoracotomy and a SIRC approach can be an effective therapeutic option.

Postoperative delirium does not affect cardiopulmonary exercise testing in aged patients undergoing cardiac valve surgery.

BACKGROUND: The effect of delirium on cardiopulmonary exercise testing (CPX) is unknown. This retrospective study was to examine the effect of delirium on CPX at discharge in aged patients undergoing cardiac surgery. METHODS: This study included seventy patients aged 70 or older undergoing cardiac valve surgery, who entered our ICU and were discharged from our hospital between June 2016 and July 2018. All patients received active exercise by our rehabilitation team from the first postoperative day and were performed a CPX on a cycle ergometer before discharge. The anaerobic threshold oxygen uptake and the slope of the relationship between carbon dioxide output and minute ventilation were examined. We obtained the patient's data, including patient's characteristics, cardiac function, anesthesia data, laboratory data, ICU data, and length of ICU and hospital stay. Data were analyzed by unpaired t test or Fisher's exact test. P < 0.05 was considered statistically significant. RESULTS: Of the 70 patients, 21 patients experienced delirium during ICU stay. The delirium group needed longer administration of sedatives and longer ICU stay and showed higher CRP value and lower renal function but similar cardiopulmonary function before discharge from our hospital compared with the non-delirium group. CONCLUSIONS: Patients with a history of delirium during ICU showed higher CRP value and lower renal function before discharge, but the CPX values at discharge were not significantly affected by delirium.

Cardiac calcified amorphous tumor with mitral valve perforation: A case report.

Cardiac calcified amorphous tumors are rare non-neoplastic intracavitary masses. Herein, we report a case of a 75-year-old woman who presented with dyspnea on exertion and multiple cerebral infarctions 3 months prior. Transthoracic echocardiography showed severe mitral regurgitation from the posterior mitral leaflet with valve perforation and severe mitral annular calcification. In addition, we observed a 13 mm mobile high echogenic mass, suggesting healed infective endocarditis. The mass was successfully resected, and the mitral valve was replaced with a bovine pericardial patch for the decalcified annulus. Histopathological examination confirmed cardiac calcified amorphous tumor; the postoperative course was uneventful. Mitral valve replacement and annulus patch repair effectively prevented postoperative recurrent systemic embolization. .

Long-term outcome of extensive mitral valve reconstruction with autologous pericardium and artificial chordae for treatment of destructive active infective endocarditis of the mitral valve.

OBJECTIVE: Mitral valve (MV) repair is a well-accepted surgical approach for infective endocarditis (IE). In our hospital, extensive MV reconstruction with fresh autologous pericardium (AP) and artificial chordae (AC) has been performed for patients with profoundly extensive and destructive IE in which valve reconstruction would be extremely challenging, especially in young patients to avoid mechanical valve replacement. Long-term outcome including the future performance of the newly created leaflet has not been established. METHODS: Five patients (54 (38-60) years of age; 3 men, 2 women) underwent this procedure from January 2011 to April 2022. In all patients, preoperative cardiac function was good (left ventricular ejection fraction, 69 (66-75)). After complete debridement of the infective valve tissue, the MV was reconstructed with large, fresh, trimmed AP and AC. RESULTS: The reconstructed leaflets were anterior in three patients and posterior in four, and AC were placed in four patients. All patients showed an uneventful postoperative course and were discharged to home 36 (28-42) days postoperatively after completion of intravenous antibiotic therapy. Pre-discharge echocardiography revealed no or trivial mitral regurgitation (MR) in all patients. The median follow-up period was 9.6 (6.0-10.4) years, and no patients developed recurrence of the IE. The latest echocardiography in four patients showed trivial/mild MR with good leaflet function. One patient developed recurrence of MR, 5 months postoperatively. CONCLUSIONS: The short- and long-term outcomes of this procedure might be acceptable. This procedure might be considered as an effective and valuable option, especially in young patients.

Efficacy of non-obstructive aortic angioscopy for detecting a thoracic aortic graft rupture: a case report.

BACKGROUND: Non-anastomotic thoracic aortic graft rupture is extremely rare and difficult to diagnose. Non-obstructive general angioscopy can help monitor the aortic intima and detect the locations of abnormal findings, while aortic angioscopy can detect vulnerable plaques in the aorta, which are difficult to visualize using conventional diagnostic methods. Herein, we report the case of a patient with non-anastomotic thoracic aortic graft rupture diagnosed using non-obstructive aortic angioscopy. CASE PRESENTATION: An 85-year-old man who had undergone total arch replacement 5 years prior complained of chest pain. Emergent contrast-enhanced computed tomography (CT) revealed an intra-mediastinal hematoma around the vascular graft of the ascending aorta and angiography revealed pooling of contrast medium on the dorsal side of the vascular graft. We suspected extravasation of the thoracic vascular graft. Aortic angioscopic examination revealed a red vascular graft defect that matched extravasation at the contralateral level of the prosthetic left common carotid artery branch. Subsequently, non-anastomotic thoracic aortic graft rupture was diagnosed. The patient underwent a two-debranching thoracic endovascular aortic repair (Zone 0) with a right subclavian artery-left common carotid artery-left subclavian artery bypass. Postoperative angiography revealed disappearance of the extravasation from the graft rupture site, patent grafted vessels with flow, and no endoleak. Follow-up CT at 6 months postoperatively showed no extravasation. CONCLUSIONS: To our knowledge, this is the first report of non-anastomotic thoracic aortic graft rupture detected using non-obstructive aortic angioscopy. Aortic angioscopy can help establish a definitive diagnosis in patients with aortic graft rupture.

Successful surgical treatment of delayed left ventricular pseudoaneurysm related to Candida albicans infection after repair of ventricular septal rupture complicating acute myocardial infarction.

Left ventricular (LV) pseudoaneurysm is a rare complication after postinfarction repair of ventricular septal rupture (VSR), and surgical treatment of this condition due to mycosis has rarely been reported. We report a rare case of successful surgical treatment of delayed LV pseudoaneurysm related to Candida albicans infection after repair of VSR due to myocardial infarction. A 75-year-old woman was admitted for fever and severe inflammatory reaction. Two and a half years previously, she had undergone postinfarct VSR repair and was treated for mycotic infective endocarditis due to C. albicans. Transthoracic echocardiography and computed tomography revealed a LV pseudoaneurysm (maximum transverse diameter 6.2 cm). The cause of the LV pseudoaneurysm was suspected to be infectious, and broad-spectrum antibiotic treatment was started. Fourteen days after admission, she developed acute abdominal pain and an elevated ß-D-glucan level because the LV pseudoaneurysm ruptured. Emergency surgical treatment was performed with antimycotic drug therapy. The LV wall defect was reconstructed using bovine pericardium under cardiopulmonary support. Her postoperative course was good, and she was discharged to home. Echocardiography revealed no recurrence of the LV pseudoaneurysm at 4 months postoperatively. During 1 year of follow-up, the patient had been doing well without any infection or adverse event. .

Detrimental effects of elevated transpulmonary gradient on outcomes following restrictive mitral annuloplasty in patients with pre-existing pulmonary hypertension.

BACKGROUND: This study retrospectively examined the association between elevated trans-pulmonary gradient (TPG), which reflects pre-capillary contribution to pulmonary hypertension (PH), and postoperative pulmonary hemodynamics and outcomes following restrictive mitral annuloplasty (RMA) in patients with pre-existing PH. METHODS: Pre- and postoperative (1 month) cardiac catheterization was performed in 64 patients with severely impaired left ventricular function (i.e., ejection fraction ≤40%) and pre-existing PH (mean pulmonary artery pressure (PAP) ≥25 mmHg) who underwent RMA. Patients were segregated into two groups: low TPG (≤12 mmHg) and elevated TPG (>12 mmHg). The mean follow-up period was 54±27 months. The primary outcome seen was a change in pulmonary hemodynamics after RMA; secondary outcomes were composite adverse events, including all-cause mortality and readmission for heart failure. RESULTS: Compared to the low TPG group, patients in the elevated TPG group were more likely to show a postoperative mean PAP of ≥25 mmHg (84% vs. 38%), TPG of >12 mmHg (79% vs. 11%), and pulmonary vascular resistance of ≥240 dynes/sec/cm-5 (84% vs. 6.7%) (all P<0.001), although both groups showed comparable degrees of mitral regurgitation improvement. Serial echocardiography demonstrated that Doppler-derived systolic PAP, which once decreased in both groups, remained stable in the low group while steadily increasing in the elevated group (group effect P<0.001). Patients with elevated TPG had lower freedom from composite adverse events (5-year, 20% vs. 70%, P=0.003). After adjusting for baseline covariates, the elevated TPG was independently associated with increased risk of adverse events (adjusted hazard ratio 2.9, 95% CI: 1.2-6.9, P=0.017). CONCLUSIONS: Elevated TPG negatively affects postoperative pulmonary hemodynamics and late outcomes in patients with advanced cardiomyopathy and pre-existing PH who have undergone RMA. These findings suggest that the assessment of TPG should be included in post-RMA risk stratification.

Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes.

BACKGROUND: In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024). CONCLUSIONS: NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.

Incidence, determinants and clinical impact of left ventricular function recovery after surgical treatments for ischaemic cardiomyopathy.

OBJECTIVES: This retrospective study aimed to clarify the incidence, determinants and clinical impact of left ventricular (LV) function non-recovery after coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy. METHODS: A total of 490 patients with ischaemic cardiomyopathy (LV ejection fraction ≤ 40%) undergoing CABG were analysed. Follow-up echocardiography was performed at 1 month, 1 year, and annually thereafter. LV function recovery was defined as ejection fraction (EF) ≥40% at least once during follow-up. LV function non-recovery was defined as EF <40% at any follow-up. The primary and secondary end points were changes in LV function and all-cause mortality, respectively. Clinical follow-up was completed in 461 patients (94.1%; mean follow-up: 64.5 ± 45.5 months). RESULTS: During follow-up, echocardiographic assessments were performed 1863 times (mean, 3.8 ± 2.4), and 193 patients (39.4%) exhibiting LV function non-recovery were identified. Overall survival was significantly higher in the recovery group (53.9%) than in the non-recovery group (31.4%) at 10 years (P < 0.001). Independent predictors of LV function non-recovery were preoperative LV end-systolic diameter [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04-1.10; P < 0.001] and bilateral internal thoracic artery grafting (OR 0.61, 95% CI 0.39-0.95; P = 0.028). In a multivariable Cox proportional hazards model, LV function non-recovery was significantly associated with all-cause mortality (hazard ratio 2.14, 95% CI 1.60-2.86; P < 0.001). CONCLUSIONS: Almost 40% of patients with ischaemic cardiomyopathy undergoing CABG did not achieve LV function recovery and were associated with poor prognosis. To achieve LV function recovery, CABG with bilateral internal thoracic artery may be recommended before excessive LV remodelling occurs. CLINICAL TRIAL REGISTRATION NUMBER: Institutional review board of Osaka University Hospital, number 16105.

Surgical Ablation Concomitant With Nonmitral Valve Surgery for Persistent Atrial Fibrillation.

BACKGROUND: Consensus regarding an optimal atrial fibrillation (AF) ablation lesion set concomitant with aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) has not been established. METHODS: We enrolled 125 consecutive patients (89 men; 70 ± 8 years old) with persistent AF who underwent radiofrequency-based pulmonary vein isolation (PVI) (PVI group, n = 53) or a Cox-Maze procedure (Maze group, n = 72) with AVR and/or CABG. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent Cox-Maze with and those who underwent PVI, we established weighted Cox proportional-hazards regression models with inverse probability of treatment weighting. Mean follow-up was 63 ± 34 months (maximum, 154 months). RESULTS: There was 1 in-hospital death in each group. Patients who underwent Cox-Maze showed a higher freedom from AF at all follow-up examinations. After the operation, there were 32 deaths, 13 thromboembolisms, 8 hemorrhagic events, and 22 heart failure readmissions. The Maze group had higher rates for 5-year survival (88% vs 64%, P = .013) and freedom from composite events (74% vs 42%, P < .001). After adjustment with inverse probability of treatment weighting, the Cox-Maze procedure still showed a lower risk of overall mortality (adjusted hazard ratio, 0.38; 95% confidence interval, 0.21-0.66; P = .001) and composite adverse events (adjusted hazard ratio, 0.52; 95% confidence interval, 0.35-0.76; P = .001). CONCLUSIONS: In patients with persistent AF indicated for nonmitral valve surgery, a concomitant Cox-Maze procedure resulted in superior AF- and event-free survival compared with PVI, without increased risk of early mortality. These findings may assist decision making for surgical management of persistent AF concomitant with AVR and/or CABG.

Surgical Aortic Valve Replacement for Aortic Stenosis in Dialysis Patients　- Analysis of Japan Cardiovascular Surgery Database.

BACKGROUND: Perioperative risk during surgical aortic valve replacement (SAVR) is reportedly high in dialysis patients. We aimed to determine the postoperative mortality and morbidity and identify the perioperative risk factors of mortality during SAVR in dialysis-dependent patients.Methods and Results:From the Japan Adult Cardiovascular Surgery Database, we compared 2,875 dialysis-dependent patients with 18,839 non-dialysis patients who all underwent SAVR between January 2013 and December 2016. The operative mortality was 8.7% vs. 2.0% in the dialysis and non-dialysis groups, respectively. Multivariate stepwise logistic regression analysis for operative mortality revealed 8 independent risk factors including age (odds ratio [OR]=1.2), concomitant coronary artery bypass grafting (OR=1.5), peripheral arterial disease (OR=1.9), atrial fibrillation (OR=2.5), New York Heart Association class IV (OR=2.5), liver dysfunction (OR=5.8), reduced left ventricular function (OR=1.4), and history of previous cardiac surgery (OR=2.1). In addition, 8 postoperative predictors of operative mortality were identified including bleeding deep sternal infection (OR=3.4), prolonged ventilation (OR=5.4) and gastrointestinal complications (OR=10.3). CONCLUSIONS: Compared with non-dialysis patients, SAVR in dialysis patients was associated with high rates of mortality and morbidity. An appropriate surgical strategy and careful perioperative assessment and management for prevention of infection, and respiratory and gastrointestinal complications might contribute to improved clinical outcomes after SAVR in these patients.

Restrictive mitral annuloplasty with or without coronary artery bypass grafting in ischemic mitral regurgitation.

AIMS: In patients with ischaemic mitral regurgitation (MR), the impact of mitral valve surgery with concomitant coronary artery bypass grafting (CABG) on post-operative survival and left ventricular (LV) reverse remodelling remains unknown. Therefore, we investigated these outcomes following restrictive mitral annuloplasty (RMA) with and without CABG in those patients. METHODS AND RESULTS: This study included 309 patients with chronic MR and ischaemic cardiomyopathy for whom concomitant CABG was indicated (n = 225) or not indicated (n = 84) with RMA. The primary endpoint was all cause mortality during the follow-up, and the secondary endpoint was defined as the composite of mortality and re-admission for heart failure. Linear mixed model was used to analyse serial echocardiographic changes in LV function. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent RMA with and those who underwent it without CABG, we established weighted Cox proportional-hazards regression models with inverse-probability-of-treatment weighting. Pre-operatively, there were no intergroup differences in age (RMA with CABG, 67 ± 9 vs. RMA without CABG, 68 ± 11, P = 0.409) and logistic EuroSCORE II (16 ± 14 vs. 15 ± 15%, P = 0.496). The 30-day mortalities were 2.7% and 3.6%, respectively (P = 0.67). During follow-up with a mean duration of 72 ± 37 months (range, 5.6-179), there were 157 deaths and 105 re-admissions for heart failure. Overall 1-year and 5-year survival rates were 83 ± 2% and 58 ± 3%, respectively. Patients who did not receive CABG with RMA had a significantly lower 5-year survival rate (45% vs. 63%, P = 0.049) and freedom from adverse events defined as mortality and/or admission for heart failure (19% vs. 43%, P < 0.001) than those who did. After adjustments for clinical covariates with inverse-probability-of-treatment weighting, concomitant CABG was identified as an independent protective factor for adverse events (hazard ratio: 0.53; 95% confidence interval: 0.44-0.64; P < 0.001). Along with significant MR reduction, LV function parameters changed over time after surgery in both groups, with greater improvements in patients who underwent RMA with CABG (time effect, P < 0.001; and interaction effect, P = 0.002). CONCLUSIONS: RMA can be performed with an acceptable operative mortality, irrespective of indications for CABG. Patients with ischaemic MR for whom CABG is indicated with RMA are more likely to show better long-term and event-free survival and greater improvements in LV systolic function. The optimal revascularization strategy should be discussed with a heart team whenever indicated in patients with ischaemic MR; otherwise, they may miss the opportunity to benefit from concomitant CABG during subsequent RMA.

Equations Estimating the Predissected Diameter of the Ascending Aorta for Acute Type A Aortic Dissection.

BACKGROUND: A successful endovascular treatment for acute type A dissection has been recently reported. However, there has been no consensus regarding the appropriate stent graft size based on the estimated predissected aortic diameter for this pathology. METHODS: We developed new equations for estimating the predissected ascending aorta and aortic arch by investigating computed tomography images that had been scanned less than 3 years before dissection. From 684 patients with type A AAD, 28 were matched for the study. We measured the predissected whole circumference length (pre-wCL), postdissected whole circumference length (post-wCL), postdissected true lumen circumference length (post-tCL), postdissected major diameter (post-Dma), and postdissected minor diameter (post-Dmi) of the acutely dissected aorta. This was followed by the calculation of (post-tCL + post-wCL)/2 and (post-Dma + post-Dmi)/2. Six equations (linear function) and modified equations were derived from each of the abovementioned parameters. RESULTS: Four equations (post-wCL, post-Dma, [post-tCL + post-wCL]/2, and [post-Dma + post-Dmi]/2) had nearly the same bias and accuracy (<9.42 mm). For clinical use, we also developed one modified equation using the post-wCL (y = 0.9x) among four parameters because of its simplicity and decreased the possibility of measurement error. The biases of circumference length and accuracy were 5.5 ± 4.9 mm and 84.6%, respectively, and they improved to 4.4 ± 3.3 mm and 93.4% in cases with a ratio of post-tCL/post-wCL of 0.66 or more. CONCLUSIONS: Our newly developed equation can be used to calculate the predissected ascending aortic diameter and aortic arch diameter in cases of acute type A dissection.

Equations for Estimating the Predissected Diameter of the Descending Aorta From Computed Tomographic Images at the Onset of Aortic Dissection.

BACKGROUND: Estimation of the predissected descending aortic diameter is important for deciding on the size of a stent graft in cases of acute aortic dissection. However, no equations for estimating this diameter have been previously reported. METHODS AND RESULTS: We developed and validated new equations by investigating computed tomography images that were scanned within 3 years before dissection and those that were scanned immediately after the onset of dissection. Among 1127 patients with acute aortic dissection (425 type A and 702 type B), 36 were matched for the study from October 2005 to March 2017 at 4 centers. New equations were developed in 17 patients and validated in 19 patients. We measured the predissected whole circumference length (CL) and postdissected whole CL, true lumen CL, the major diameter, and the minor diameter of the acutely dissected aorta, followed by calculation of (post-trueCL+post-wholeCL)/2 and (post-major diameter+post-minor diameter)/2. Six equations (linear function) and modified equations were derived from each of the above-mentioned parameters. In the derivation sets, equations that used the parameter of (post-trueCL+post-wholeCL)/2 were strongly correlated with pre-wholeCL (Y=0.9433x+5.0147; R2=0.9001) and showed significantly less bias compared with the other 5 equations (P<0.0001). In validation sets using this equation, the mean bias of the circumference length and diameter was 2.7±2.8 and 0.85±0.89 mm, respectively. A total of 99.2% of the calculated values were within 3 mm in diameter or less. CONCLUSIONS: Our newly developed equations can be used to calculate the predissected aortic diameter in cases of acute aortic dissection and might help to decide the size of the stent graft.

To what extent can 3D model replicate dimensions of individual mitral valve prolapse?

Determining the complex geometry of mitral valve prolapse is often difficult. We constructed 3D models of six prolapsed mitral valves for surgical assessment, and evaluated how accurately the models could replicate individual valve dimensions. 3D polygon data were constructed based on an original segmentation method for computed tomography images. The model's replication performance was confirmed via dimensional comparison between the actual hearts during surgery and those models. The results revealed that the prolapsed segments matched in all cases; however, torn chordae were replicated in four cases. The mean height differences were 0.0 mm (SD 1.6, range - 2 to + 2 mm) for the anterolateral side, 0.0 mm (SD 1.7, range - 2 to + 2 mm) for the prolapsed leaflet center, and - 1.5 mm (SD 0.6, range - 1 to - 2 mm) for the posteromedial side. Regression analysis showed a strong and positive correlation, and Bland-Altman plots indicated quantitative similarity of the models to the actual hearts. We concluded that our 3D valve models could replicate the actual mitral valve prolapses within acceptable dimensional differences. Our concepts are useful for better 3D valve creation and better surgical planning with reliable 3D valve models.

A life-threatening infection due to Corynebacterium striatum: a lesson learned.

Because the genus Corynebacterium colonize the human skin, detection of Corynebacterium striatum in a sterile blood specimen is sometimes considered as contamination. An 80-year-old man who underwent cardiovascular operation presented with high-grade fever postoperatively. Corynebacterium striatum was detected in the blood and wound exudate, and the patient was diagnosed with mediastinitis due to Corynebacterium striatum. One month earlier, a patient with similar symptoms due to C. striatum-related mediastinitis died in our care. The Corynebacterium striatum isolates from both patients had identical biochemical and genetic characteristics, suggesting that Corynebacterium striatum was acquired nosocomially. We have learnt a lesson from this negative experience: early diagnosis of Corynebacterium striatum-related infection and early administration of glycopeptide antibiotics could have saved this patient. It is notable that C. striatum can cause life-threatening infection after cardiovascular operation.