Bilateral versus Single Internal Thoracic Artery Grafting Strategies Supplemented by Radial Artery Grafting.

PURPOSE: It is unclear if a second or third arterial graft can improve clinical outcomes in coronary artery bypass graft surgery. We compared the outcomes of bilateral internal thoracic artery (BITA) plus radial artery (RA) grafting versus left internal thoracic artery (LITA) plus RA grafting after off-pump coronary artery bypass grafting. MATERIALS AND METHODS: Between January 2009 and December 2020, a total of 3007 patients with three-vessel coronary artery disease who underwent off-pump coronary artery bypass were analyzed. Among them, 971 patients received total arterial grafting using LITA. We divided the patients into two groups [group A, BITA+RA grafting (n=227) and group B, LITA+RA grafting (n=744)], and compared the survival and major adverse cardiac and cerebrovascular event (MACCE) rates between the two groups at 10 years. RESULTS: After risk adjustment with inverse probability treatment weighting methods, the freedom from all-cause mortality was 93.1% and 88.3% in groups A and B, respectively (p=0.140). The freedom from MACCE rates were 68.3% and 89.0%, respectively (p<0.0001). LITA plus RA grafting [hazard ratio (HR): 1.3, 95% confidence interval (CI): 1.05-2.37, p=0.025] and incomplete revascularization (HR 1.2, 95% CI: 0.70-2.15, p=0.046) were significant risk factors for MACCEs in multivariable Cox regression analysis. CONCLUSION: The rates of MACCEs were lower with LITA plus RA grafting than with BITA plus RA grafting in total arterial revascularization. Furthermore, complete revascularization improved long-term outcomes following total arterial grafting.

Hemostatic efficacy of a flowable collagen-thrombin matrix during coronary artery bypass grafting: a double-blind randomized controlled trial.

BACKGROUND: Flowable hemostatic agents have the advantage of being able to be applied to irregular wound surfaces and difficult to reach areas. We sought to compare the effectiveness and safety of the flowable hemostatic sealants Collastat® (collagen hemostatic matrix, [CHM]) and Floseal® (gelatin hemostatic matrix, [GHM]) during off-pump coronary artery bypass (OPCAB). METHODS: In this prospective, double-blind, randomized controlled trial, 160 patients undergoing elective OPCAB surgery were enrolled between March 2018 and February 2020. After primary suture of the aortocoronary anastomosis, an area of hemorrhage was identified, and patients received either CHM or GHM (n = 80, each). Study endpoints were the following: proportion of successful intraoperative hemostasis and time required for hemostasis overall postoperative bleeding, proportion of transfusion of blood products, and surgical revision for bleeding. RESULTS: Of the total patients, 23% were female, and the mean age was 63 years (range 42-81 years). Successful hemostasis proportion within 5 min was achieved for 78 patients (97.5%) in the GHM group, compared to 80 patients (100%) in the CHM group (non-inferiority p = 0.006). Two patients receiving GHM required surgical revision to achieve hemostasis. There were no differences in the mean time required to obtain hemostasis [GHM vs. CHM, mean 1.49 (SD 0.94) vs. 1.35 (0.60) min, p = 0.272], as confirmed by time-to-event analysis (p = 0.605). The two groups had similar amounts of mediastinal drainage for 24 h postoperatively [538.5 (229.1) vs. 494.7 (190.0) ml, p = 0.298]. The CHM group required less packed red blood cells, fresh frozen plasma, and platelets for transfusion than the GHM group (0.5 vs. 0.7 units per patient, p = 0.047; 17.5% vs. 25.0%, p = 0.034; 7.5% vs. 15.0%, p = 0.032; respectively). CONCLUSIONS: CHM was associated with a lower need for FFP and platelet transfusions. Thus, CHM is a safe and effective alternative to GHM. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04310150.

Effect of Preoperative Administration of Intravenous Ferric Carboxymaltose in Patients with Iron Deficiency Anemia after Off-Pump Coronary Artery Bypass Grafting: A Randomized Controlled Trial.

Patients scheduled for cardiac surgery often have anemia and iron deficiency. We investigated the effect of the preoperative administration of intravenous ferric carboxymaltose (IVFC) in patients with iron deficiency anemia (IDA) who were due to undergo off-pump coronary artery bypass grafting (OPCAB). Patients who were due to undergo elective OPCAB between February 2019 and March 2022 who had IDA (n = 86) were included in this single center, randomized, parallel-group controlled study. The participants were randomly assigned (1:1) to receive either IVFC or placebo treatment. Postoperative hematologic parameters [hemoglobin (Hb), hematocrit, serum iron concentration, total iron-binding capacity, transferrin saturation, transferrin concentration, and ferritin concentration] and the changes in these parameters during the follow-up period were the primary and secondary outcomes, respectively. The tertiary endpoints were early clinical outcomes, such as the volume of mediastinal drainage and the need for blood transfusions. IVFC treatment significantly reduced the need for red blood cell (RBC) and platelet transfusions. Despite receiving fewer RBC transfusions, patients in the treatment group had higher levels of Hb, hematocrit, and serum iron and ferritin concentrations during weeks 1 and 12 after surgery. No serious adverse events occurred during the study period. Preoperative IVFC treatment in patients with IDA undergoing OPCAB improved the values of the hematologic parameters and iron bioavailability. Therefore, is a useful strategy for stabilizing patients prior to OPCAB.

Clinical Outcomes of Endoscope-Assisted Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension.

PURPOSE: Pulmonary thromboembolism is a potentially life-threatening condition in patients with heart disease; however, limited studies discussing long-term outcomes exist. This study aimed to investigate the long-term outcomes of pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), focusing on the improvement of functional class and right ventricular (RV) pressure. MATERIALS AND METHODS: Clinical data of patients with CTEPH were obtained from Yonsei Hospital between May 2012 and December 2021, and reviewed retrospectively. Twenty-six patients underwent endoscope-guided PEA during the study period, and the mean follow-up duration was 24.8±23.4 months. RESULTS: After PEA, most patients (88.5%) were weaned from inotropes without extracorporeal membrane oxygenation support during the first few days. Two patients (7.6%) had cerebrovascular accidents without neurological deficits. On echocardiography, the RV systolic pressure and tricuspid regurgitation grades significantly improved (p<0.001). Furthermore, the mean left ventricle end-diastolic diameter was significant increased (p=0.003), and the left ventricular end-systolic diameter increased (p<0.001). The median intensive care unit stay was 3.0±9.4 days, and median hospital stay 16.0±26.5 days. The 5-year survival rate was 95.5%, and the 5-year freedom rate of cardiac death was 100%. There was a marked improvement in New York Heart Association (NYHA) status (p<0.001). Cox regression suggested that the main pulmonary artery (MPA) involvement is a significant predictor of non-improvement in functional class post-PEA. CONCLUSION: Mortality rates are low and patients experience a marked improvement in NYHA class and health status after PEA. Moreover, MPA involvement may affect functional outcomes.

A Randomized Trial of Clopidogrel vs Ticagrelor After Off-Pump Coronary Bypass.

BACKGROUND: This study aimed to compare the outcomes of aspirin in combination with either ticagrelor or clopidogrel after off-pump coronary artery bypass (OPCAB) in patients with clopidogrel resistance. METHODS: Between November 2014 and November 2020, 1739 patients underwent OPCAB. Aspirin and clopidogrel treatment was initiated the day after surgery. On postoperative days 7 to 9, clopidogrel resistance was evaluated using a point-of-care assay. A total of 278 (18.9%) patients had clopidogrel resistance ( platelet reaction unit >208) and were enrolled in the study. The study investigators excluded patients with coresistance to aspirin (n = 74) and divided the remaining patients (mean age, 67.4 ± 8.5 years) into 2 groups (an aspirin and ticagrelor group [AT group; n = 102] and an aspirin and clopidogrel group [AC group; n = 102]), randomly assigned using a 1:1 ratio block table. The primary end point was graft patency and major adverse cardiovascular events (MACEs; defined as the composite of cardiovascular mortality, myocardial infarction, and repeat revascularization at 1 year after OPCAB), and the coprimary end point was the graft patency rate. The data were analyzed using the intent-to-treat method. RESULTS: The graft occlusion rates in the AT and AC groups were 3.9% and 5.9%, respectively (P = .52). Neither death from cardiovascular causes (1.0% vs 2.9%; P = .32) nor myocardial infarction showed significant differences (1.0% vs 3.9%; P = .18). No significant difference in the rates of major bleeding were found between the 2 groups (P = .75). However, the AT group was associated with a lower rate of MACEs after OPCAB (hazard ratio, 0.77; 95% CI, 0.684-0.891; P = .01). CONCLUSIONS: These results suggest that ticagrelor may be associated with reducing MACEs in patients with clopidogrel resistance after OPCAB.

Transit-Time Flow Measurement and Outcomes in Coronary Artery Bypass Graft Patients.

Transit-time flowmetry (TTFM) is commonly used during coronary artery bypass grafting for intraoperative graft assessment. This study aimed to investigate whether TTFM values were predictive of graft failure and major adverse cardiac and cerebrovascular events (MACCEs). Between 2011 and 2018, 1933 patients with 3-vessel coronary artery disease who underwent off-pump coronary artery bypass were retrospectively analyzed. Among them, 1288 sequential venous grafts in 538 consecutive patients were measured using TTFM's 2 parameters, pulsatility index (PI) and flow (mL/min). The anastomoses were divided in the 3 groups depending on the anastomotic site: group A, first side-to-side anastomoses (n = 538), group B; second side-to-side (n = 212), group C; end-to-side (n = 538). MACCEs were related to TTFM. The mean clinical follow-up time was 64.8 ± 21.2 months. Postoperative graft patency was confirmed with multi-slice computed tomography or coronary angiography (follow-up interval: 64.8 ± 50.4 and 27.8 ± 20.5 months based on the date of examination). The 5-year survival rate was 93.7%. The mean graft flow was 59.1 ± 31.3, 41.0 ± 25.2, and 38.9 ± 22.8 mL/minute, and the PI was 2.2 ± 1.3, 2.5 ± 3.4, and 2.4 ± 2.5, in groups A, B, and C, respectively. Graft failure occurred in 23/1055 (2.2%) anastomoses. The 5-year MACCE rate was 6.9% (37/538 patients). Kaplan-Meier analysis revealed that graft patency was significantly lower in low MGF (p = 0.044) and high PI (p < 0.001). Multivariable logistic analysis showed that high PI (>5; HR 2.276; 95%CI 2.188-2.406, p < 0.001) was an independent risk factor for MACCEs. The cutoff values for PI of sequential grafts were 3.65, 3.55, and 3.17 in groups A, B, and C, respectively for the prediction of MACCE. A high PI predicts more predictive poor outcomes of sequential venous grafts after surgery than the low mean graft blood flow.

Risk factors for neuromuscular complications in lower limbs after lung transplantation.

Objective: This study aimed to analyze the prevalence and risk factors of neuromuscular complications after lung transplantation (LT), as well as the association between neuromuscular complications and extracorporeal membrane oxygenation (ECMO) support. Methods: We retrospectively included 201 patients who underwent LT between 2013 and 2020. Patients were classified into three groups based on the presence and the pattern of postoperative leg weakness: no weakness group, asymmetric weakness group, and symmetric weakness group. Comorbidities, duration of ECMO therapy, and postoperative complications were compared between the three groups. Results: Of the 201 recipients, 16 (8.0%) and 29 (14.4%) patients developed asymmetric and symmetric leg weakness, respectively. Foot drop was the main complaint in patients with asymmetric weakness. The presumed site of nerve injury in the asymmetric weakness group was the lumbosacral plexus in 8 (50%), peroneal nerve in 4 (25%), sciatic nerve in 2 (12.5%), and femoral nerve in 2 (12.5%) patients. In multivariate analysis, the use of preoperative ECMO was found to be independently associated with asymmetric weakness (OR, 3.590; 95% CI [1.227-10.502]). Symmetric leg weakness was associated with age at LT (1.062 [1.002-1.125]), diabetes mellitus (2.873 [1.037-7.965]), myositis (13.250 [2.179-80.584]), postoperative continuous renal replacement therapy (4.858 [1.538-15.350]), and duration of stay in the intensive care unit (1.052 [1.015-1.090]). Conclusion: More than 20% of patients developed leg weakness after LT. Early suspicion for peripheral neuropathy is required in patients after LT who used ECMO preoperatively, and who suffered from medical complications after LT.

Long-Term Outcomes of Preoperative Atrial Fibrillation in Cardiac Surgery.

Background: Atrial fibrillation (Afib) is a marker of increased cardiovascular morbidity and mortality. Owing to the increased prevalence of Afib in patients undergoing cardiac surgery, assessing the effect of Afib on postsurgical outcomes is important. We aimed to analyze the effect of preoperative Afib on clinical outcomes in patients undergoing cardiac surgery using a large surgical database. Methods: This retrospective cohort study was based on the national health claims database established by the National Health Insurance Service of the Republic of Korea from 2009 to 2015. Diagnosis and procedure codes were used to identify diseases according to the International Statistical Classification of Diseases, 10th revision. Results: We included 1,037 patients (0.1%) who had undergone cardiac surgery from a randomized 1,000,000-patient cohort, and 15 patients (1.5%) treated with isolated surgical Afib ablation were excluded. Of these 1,022 patients, 412 (39.7%), 303 (29.2%), and 92 (9.0%) underwent coronary artery bypass, heart valve surgery, and Cox-maze surgery, respectively. Preoperative Afib was associated with higher patient mortality (p=0.028), regardless of the surgical procedure. Patients with preoperative Afib (n=190, 18.6%) experienced a higher cumulative risk of overall mortality (hazard ratio [HR], 1.435; 95% confidence interval [CI], 1.263-2.107; p=0.034). Subgroup analysis revealed a reduced risk of overall mortality with Cox-maze surgery in Afib patients (HR, 0.500; 95% CI, 0.266-0.938; p=0.031). Postoperative cerebral ischemia or hemorrhage events were not related to Afib. Conclusion: Preoperative Afib was independently associated with worse long-term postoperative outcomes after cardiac surgery. Concomitant Cox-maze surgery may improve the survival rate.

Time-dependent pathobiological and physiological changes of implanted vein grafts in a canine model.

Although autologous vein grafting is essential, the high vein failure rate and specific clinical interventions are not clear, so a potential treatment is critically needed; thus, complex analyses of the relationship between pathobiological and physiological processes in preclinical are essential. The interposition of the femoral vein was performed in a canine model. Maximized expansion and velocity were measured at 8 weeks post-implantation, and a relative decrease was observed at 12 weeks. However, NI formation and NI/Media ratio significantly increased time dependently, and differences between the mechanical properties were observed. Additionally, RhoA-mediated TNF-α induced by rapid structural changes and high shear stress was confirmed. After adaptation to the arterial environment, vascular remodeling occurred by SMC proliferation and differentiation, apoptosis and autophagy were induced through YAP activity without vasodilation and RhoA activity. Our results show that understanding pathobiological processes in which time-dependent physiological changes contribute to vein failure can lead to a potential strategy. The implanted vein graft within the arterial environment undergoes pathobiological processes through RhoA and YAP activity, leading to pathophysiological changes.

The long-term fate of ascending aorta aneurysm after wrapping versus replacement.

OBJECTIVE: The study objective was to examine the long-term fate of aortic diameter expansion at 4 cardiac regions (annulus, sinus, ascending aorta, and proximal arch) after wrapping or replacement during aortic valve surgery of the moderately dilated ascending aorta. METHODS: From January 1995 to December 2018, 964 consecutive patients who underwent aortic valve replacement at our institution were reviewed. Of them, 204 (mean age, 60.7 ± 7.4 years) underwent ascending aorta wrapping (n = 96) or replacement (n = 108) for a moderately dilated ascending aorta (40 to 55 mm). The overall fate of the aortic diameter was analyzed with a linear mixed-effect model. The median follow-up duration was 7.1 years. RESULTS: After propensity score matching, the baseline maximal ascending aortic diameter median value was 47.3 ± 3.1 mm and 49.4 ± 13.5 mm in the wrapping and replacement groups, respectively. The annulus, sinus, and ascending aorta did not redilate in either group. The proximal aortic arch diameter significantly increased over time (0.343 mm/year; P = .006) in the wrapping group but not in the replacement group (0.066 mm/year; P = .649). Multivariable competing risk analysis identified the initial ascending aorta diameter at the wrapping procedure as an independent risk factor of proximal arch redilation (0.071 ± 0.037, P < .001). The cutoff value was an initial ascending aorta diameter of 47.2 mm for the prediction proximal arch redilation (area under the curve, 0.703; P = .014). CONCLUSIONS: Aortic wrapping and replacement may be long-term durable treatment options in patients with a moderately enlarged ascending aorta. We suggest careful evaluation of redilation in the proximal arch after an aorta wrapping procedure.

Outcome of Extracorporeal Ventricular Assist Device for Cardiogenic Shock as a Bridge to Transplantation.

BACKGROUND: The extracorporeal ventricular assist device (e-VAD) system is designed for left ventricular support using a permanent life support console. This study aimed to determine the impact of temporary e-VAD implantation bridging on posttransplant outcomes. METHODS: We reviewed the clinical records of 6 patients with the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1, awaiting heart transplantation, who were provided with temporary e-VAD from 2018 to 2019. The circuit comprised a single centrifugal pump without an oxygenator. The e-VAD inflow cannula was inserted into the apex of the left ventricle, and the outflow cannula was positioned in the ascending aorta. The median follow-up duration was 8.4±6.9 months. RESULTS: After e-VAD implantation, lactate dehydrogenase levels significantly decreased, and Sequential Organ Failure Assessment scores significantly improved. Bedside rehabilitation was possible in 5 patients. After a mean e-VAD support duration of 14.5±17.3 days, all patients were successfully bridged to transplantation. After transplantation, 5 patients survived for at least 6 months. CONCLUSION: e-VAD may reverse end-organ dysfunction and improve outcomes in INTERMACS I heart transplant patients.

Impact of Suture Techniques for Aortic Valve Replacement on Prosthesis-Patient Mismatch.

BACKGROUND: Many variables may affect the hemodynamic performance of the aortic valve prosthesis, and suture technique remains an important factor for determining maximum valve performance. The objective of this study was to determine the suture technique that produces better hemodynamic performance for aortic valve replacement (AVR). METHODS: Patients who underwent AVR between January 2015 and September 2018 in our institution were analyzed. We compared the preoperative clinical information and 1-year postoperative hemodynamic data of interrupted pledget mattress sutures (pledgeted group), interrupted nonpledget mattress sutures (nonpledgeted group), and figure-of-8 nonpledget sutures (figure-of-eight group). We compared the incidence of prosthesis-patient mismatch (PPM) and cardiac adverse events among the groups and subanalyzed the PPM rate in a small aortic annulus (18 to 21 mm). RESULTS: A total of 439 patients underwent AVR (pledgeted, n = 212; nonpledgeted, n = 122; figure-of-eight, n = 105). The groups were similar in age (P = .359), sex (P = .055), underlying disease, and valve pathology. There was no difference in inhospital mortality or cardiac adverse events in each suture group (P = .282). The nonpledgeted suture had significantly lower moderate (P < .01) and severe PPM rates (P = .01) in patients with a small aortic annulus (18 to 21 mm). CONCLUSIONS: The interrupted nonpledget mattress suture offers complete supraannular implantation, which reduces the incidence of PPM and results in better hemodynamic improvement after small-size AVR.

Concomitant Wrapping of a Moderately Dilated Ascending Aorta during Aortic Valve Replacement: Postoperative Remodeling of a Distinctive Aorta.

PURPOSE: The long-term outcomes of aortic wrapping in patients with ascending aortic aneurysms, which are rare, but can be fatal, remain poorly understood. This retrospective study analyzed the outcomes of aortic diameter, including aortic root, ascending aorta, and proximal arch diameters, after aortic wrapping during aortic valve replacement surgery. MATERIALS AND METHODS: Ninety-six patients with ascending aortic dilation of 40-55 mm who underwent aortic wrapping during aortic valve replacement were selected for this study. Aortic diameter was measured at three levels perioperatively and at follow-up (median time of 9.1±4.2 years). A linear mixed-effects model was used to analyze aortic diameter expansion. RESULTS: Freedom from adverse aortic events (aortic dissection or rupture, reoperation, or sudden death) at 10 years was 97.9%. No significant dilation at the level of the sinuses of Valsalva (0.069 mm/year, p=0.524) or ascending aorta (0.152 mm/year, p=0.124) was observed. Significant dilation occurred at the proximal aortic arch (0.343 mm/year, p=0.006). Subgroup analysis with a multivariable linear mixed model identified initial ascending aortic diameter to be a significant predictor of proximal arch dilation (p=0.032). Receiver operating characteristic curve analysis revealed that the cut-off for the prediction of proximal arch redilation was an initial mid-ascending aortic diameter of 47.0 mm (area under the curve 0.747, 90% confidence interval 0.613-0.881, p=0.023). CONCLUSION: Aortic wrapping could be considered as a safe and long-term therapeutic option. Redilation of the proximal arch should be carefully observed during long-term follow-up.

Antimelanogenic Effect of an Oroxylum indicum Seed Extract by Suppression of MITF Expression through Activation of MAPK Signaling Protein.

In this study, the antimelanogenic effect of an ethyl acetate fraction of Oroxylum indicum Vent. seeds (OISEA) and its underlying mechanisms in melan-a cells were investigated. Antimelanogenesis activity was confirmed by assessing inhibition of tyrosinase activity and melanin content in the cells. Both transcriptional and translational expression of microphthalmia-associated transcription factor (MITF), tyrosinase, and tyrosinase related protein-1 and 2 (TYRP-1 and TYRP-2), were also examined. The results depicted that pretreatment of OISEA significantly inhibits not only tyrosinase activity, but melanin production and intracellular tyrosinase activity. By repressing the expression of tyrosinase, TYRP-1, TYRP-2, and MITF, OISEA interrupted melanin production. Additionally, OISEA interfered with the phosphorylation of p38, extracellular signal-regulated kinase 1/2 (ERK1/2), and c-Jun N-terminal kinase (JNK), with the reversal of OISEA-induced melanogenesis inhibition after treatment with the specific inhibitors SB239063, U0126, and SP600125. Overall, these results suggest that OISEA can stimulate p38, ERK1/2, JNK phosphorylation, and subsequent suppression of melanin, leading to the inhibition of melanogenic enzymes and melanin production, possibly owing to the presence of polyphenolic compounds.

Early Clinical Experience with Sutureless Aortic Valve Replacement for Severe Aortic Stenosis.

BACKGROUND: Sutureless aortic valve replacement (SU-AVR) has been developed as an alternative surgical treatment for patients with symptomatic severe aortic stenosis (AS). The aim of this study was to evaluate the clinical outcomes of SU-AVR through an assessment of hemodynamic performance and safety. METHODS: From December 2014 to June 2016, a total of 12 consecutive patients with severe AS underwent SU-AVR. The endpoints were overall survival and valve-related complications (paravalvular leakage, valve thrombosis, migration, endocarditis, and permanent pacemaker implantation). The mean follow-up duration was 18.1±8.6 months. RESULTS: The mean age of the patients was 77.1±5.8 years and their mean Society of Thoracic Surgeons score was 9.2±17.7. The mean cardiopulmonary bypass and aortic cross-clamp times were 94.5±37.3 minutes and 54.9±12.5 minutes, respectively. Follow-up echocardiography showed good prosthesis function with low transvalvular pressure gradients (mean, 13.9±8.6 mm Hg and peak, 27.2±15.0 mm Hg) at a mean of 9.9±4.2 months. No cases of primary paravalvular leakage, valve thrombosis, migration, or endocarditis were reported. A new permanent pacemaker was implanted in 1 patient (8.3%). The 1-year overall survival rate was 83.3%±10.8%. CONCLUSION: Our initial experience with SU-AVR demonstrated excellent early clinical outcomes with good hemodynamic results. However, there was a high incidence of permanent pacemaker implantation compared to the rate for conventional AVR, which is a problem that should be solved.