Minimally Invasive Valvular Surgery in the Elderly　- Safety, Early Recovery, and Long-Term Outcomes.

BACKGROUND: For elderly people, the benefit of minimally invasive cardiac surgery (MICS) is unclear, so we evaluated the safety, recovery, and long-term survival in elderly MICS patients.Methods and Results: 63 propensity score-matched pairs of 213 consecutive patients (≥70 years old) who underwent mitral and/or tricuspid valve surgery between 2010 and 2020 (121 right mini-thoracotomies vs. 92 full sternotomies) were compared. The primary outcome was safety (composite endpoint of in-hospital death or major complication). Secondary outcomes were early ambulation and discharge to home. There were no differences between the groups for in-hospital death (3.2% vs. 0.0%, P=0.157) and primary outcome (14.3% vs. 17.5%, P=0.617). The rate of early ambulation (73.0% vs. 55.6%, P=0.048) and discharge to home (66.7% vs. 49.2%, P=0.034) were significantly higher in the mini-thoracotomy group. Major complication was an independent negative predictor of early ambulation for mini-thoracotomy but not for a conservative approach. Survival was 87.8±4.4% vs. 86.8±4.7% at 5 years, which was not significantly different. CONCLUSIONS: Similar safety but better recovery were observed for mini-thoracotomy, and long-term survival was comparable between groups. Major complication was a negative predictor of early ambulation after mini-thoracotomy. Careful preoperative risk stratification would enhance the benefits of MICS in elderly patients.

Ulcer-like projections into the dilated false lumen after stent-graft placement for aortic dissection: A case report.

RATIONALE: Acute type A aortic dissection and chronic type B aortic dissection (TBAD) occurs simultaneously in rare cases. Although the development of ulcer-like projection (ULP) is associated with an increase in adverse aorta-related events, the false-lumen enlargement caused by the ULP progression is uncommon. PATIENT CONCERNS: A 72-year-old female with chronic TBAD was admitted to our unit with back and chest pain. Computed tomography revealed acute type A aortic dissection and a hematoma caused by rupturing of the descending aorta due to chronic TBAD. After endovascular intervention, the false lumen thrombosed and shrunk. DIAGNOSIS: After 9 months, a developing ULP, which projected into a dilating false lumen, was found. An impending ruptured descending aortic aneurysm was confirmed. INTERVENTIONS: Emergency Total arch replacement and thoracic endovascular aortic repair (TEVAR) was performed. OUTCOMES: The procedure was successful. One year later, regular follow-up showed that the false lumen had completely shrunk. LESSONS: ULP can arise and cause progressive dilation of false lumen after TEVAR. Careful and regular computed tomography examinations are required for early diagnosis of false lumen becoming thrombosed after TEVAR. Close follow-up and timely intervention, including TEVAR, should be considered in cases of aortic enlargement due to a newly developed ULP.

David Operation for Insufficient Pulmonary Autograft After Ross-Konno Procedure.

We report the case of a 25-year-old woman who developed severe aortic regurgitation because of pulmonary autograft root dilatation late after Ross-Konno procedure. The geometric heights of all 3 cusps were relatively small, allowing for the David operation with a 24-mm straight graft. We carefully dissected the aortic root and, the dissection process was relatively straightforward, and the basal ring could be sutured properly. The latest follow-up transthoracic echocardiogram showed normal autograft valve function and mild aortic regurgitation. Even in the Ross-Konno procedure, valve-sparing root replacement is possible, as in the Ross procedure.

"Leafletization" of Atrialized Ventricular Septum Endocardium in Ebstein Anomaly.

This case presentation of a 73-year-old man introduces a unique tricuspid valve repair with "endocardium leafletization" for Ebstein anomaly. In this procedure, an atrialized portion of the right ventricular endocardium was delaminated, starting from the level of the true tricuspid annulus, to create a neoleaflet in continuity with the displaced true leaflet. The obtained neoleaflet was then anchored to the true tricuspid annulus. Preoperative severe tricuspid regurgitation was effectively controlled with preserving sufficient leaflet mobility. This procedure can be one of the useful options for a certain lesion of Ebstein anomaly that aims to avoid excessive leaflet rotation and restore functional valve apparatus.

Tricuspidization by the raphe suspension technique in a unicuspid or bicuspid aortic valve.

Central plication to close a raphe is the most reproducible procedure in bicuspid aortic valve or unicuspid aortic valve repair; however, raphe plication is sometimes associated with systolic doming of the fused leaflet and narrowing of the valve orifice. We experienced a patient with a bicuspid aortic valve with a pliable raphe and commissure orientation close to 120°. Suspension of the raphe was performed instead of plication to create a functional commissure and achieve tricuspidization. This raphe suspension technique could be used in a patient with a unicuspid aortic valve to reconstruct a functional left lateral commissure concomitant with anterior neocommissure reconstruction using pericardium. This simple raphe suspension technique may be beneficial for some patients to avoid excessive plication.

Mitral endocarditis in hypertrophic obstructive cardiomyopathy with leaflet perforation.

We present a case of mitral endocarditis in hypertrophic obstructive cardiomyopathy with systolic anterior motion of anterior leaflet. Perforated anterior leaflet was repaired and extended septal myectomy was concomitantly performed to control systolic anterior motion and mitral regurgitation.

Very long-term outcomes of twisted auto-pericardial mitral annuloplasty.

OBJECTIVES: During mitral annuloplasty, we twisted the harvested auto-pericardium to enable adequate ring sizing and implanted it to prevent ring-related complications. Indication for twisted auto-pericardial band (APB) was limited to patients with less than severe annular dilation to ensure high reproducibility and durability. The aim of this study was to investigate the long-term outcomes of twisted APB annuloplasty. METHODS: From 1999 to 2009, 107 patients (62 ± 12 years, degenerative 92 and infective endocarditis 15) with isolated posterior mitral leaflet (PML) prolapse with inter-commissural distance of 32 mm or smaller underwent twisted APB annuloplasty. Of these, 104 patients without early leaflet repair failure were studied. Leaflet repairs were predominantly performed by quadrangular resection. Median APB size was 28 mm. RESULTS: Follow-up rate was 98.1% and duration was 10.9 ± 4.8 years. There were two early and 34 late deaths. Survival and freedom from cardiac-related death at 15 years were 61.7% ± 5.6% and 83.8% ± 4.7%, respectively. Age and male sex were independent predictors of mortality. There were four late reoperations for recurrent severe mitral regurgitation (MR), three of which were due to new chordal rupture. Freedom from reoperation and freedom from moderate or severe MR at 15 years were 93.1% ± 3.5% and 81.3% ± 6.2%, respectively. No patients developed hemolysis, ring dehiscence, or infective endocarditis. CONCLUSIONS: The long-term outcomes of twisted APB for isolated PML prolapse without severe annular dilation are satisfactory. Twisted APB annuloplasty may be a preferable option to reduce ring-related complications with sufficient durability.

Impact of Lesion Localization on Durability of Mitral Valve Repair in Infective Endocarditis.

BACKGROUND: Mitral valve (MV) repair for infective endocarditis (IE) is sometimes challenging. We investigated the durability of repair associated with the location of the infected lesion. METHODS: The study comprised 83 patients (55 ± 18 years; active, 66; healed, 17) who underwent MV repair at our institution. Patients were categorized into 5 types based on the location of the main lesion: type I, posterior leaflet (n = 36); type IIC, clear zone of anterior leaflet (n = 12); type IIR, rough zone of anterior leaflet (n = 28); and type III, annulus (n = 7). Type IIR was divided into 2 subgroups: IIR-large (>1 segment involvement, n = 9) and IIR-small (1 segment, n = 19). RESULTS: Follow-up was 95.2% completed for 7.2 ± 5.2 years. The rate of recurrent moderate or severe mitral regurgitation (MR) was 2.8% in type I, 0% in type IIC, 28.6% in type IIR, and 14.3% in type III. The freedom from recurrent moderate or severe MR was significantly lower in type IIR compared with the other types (63.1% ± 10.6% vs 96.8 ± 3.2% at 5 years, P < .001). Moreover, the recurrence rate was higher in type IIR-large (55.6%) than in type IIR-small (15.8%, P = .068). Type IIR was an independent predictor of recurrent MR (hazard ratio, 11.1, 95% confidence interval, 2.52-78.2; P = .001). CONCLUSIONS: The durability of MV repair for IE was satisfactory in posterior leaflet infection without annulus invasion and in clear zone infection of the anterior leaflet. However, rough zone infection of the anterior leaflet, especially with more than 1 segment involvement, was associated with a high risk of recurrent MR.

[Successful Treatment of Ascending Aortic Graft Infection with a Rifampicin-soaked Vascular Prosthesis and Continuous Irrigation].

A 68-year-old woman underwent replacement of the ascending aorta for acute type A aortic dissection. She was then diagnosed with postoperative methicillin-resistant Staphylococcus aureus (MRSA) infection, and the infected aortic graft was replaced with a rifampicin-soaked vascular prosthesis, which was followed by continuous irrigation using a 0.1% povidone-iodine solution. The postoperative course was uneventful, and she has been doing well for 5 years with no recurrence of infection. Prosthetic graft replacement using a rifampicin-soaked graft followed by continuous irrigation with povidone-iodine is useful for treatment of an MRSA-infected prosthetic vascular graft.

Surgical technique of double valve replacement in a patient with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder. Left ventricle dilation and valve insufficiency are complications in patients with OI and such patients are at high risk of mortality and complications related to bleeding and tissue friability during cardiac surgery. Valve dehiscence due to extreme friability of the annulus is a major complication of cardiac valve replacement with OI. We describe OI in a male patient who underwent double valve replacement with mechanical valves using a tissue protective method to prevent valve dehiscence.

Mitral leaflet restoration using a billowing leaflet in active infective endocarditis.

A key to the success of mitral valve repair in patients with infective endocarditis is the technique used for reconstruction of the missing leaflet. We report the case of a 47-year-old man with active mitral infective endocarditis. After dissection of the infected segments of P3 and the posteromedial commissure, the defect was reconstructed using tissue from a billowing A2 medial and A3 segment. Chordal transfer with an anterior chord was performed to correct the A3 mild prolapse. Follow-up echocardiography showed recovery of mitral valve morphology and function without regurgitation.

Which type of secondary tricuspid regurgitation accompanying mitral valve disease should be surgically treated?

PURPOSE: The purpose of this study was to examine changes in severity of secondary tricuspid regurgitation (TR) accompanying mitral valve disease, and to identify factors predicting failure of improvement in TR after mitral valve surgery. METHODS: We studied 99 patients who had TR of grade ≥2+ preoperatively, 47 with tricuspid annuloplasty (TAP Group) performed concurrently, and 52 with mitral surgery alone (nTAP Group). Predictors of failure of improvement in TR in the nTAP Group were analyzed. RESULTS: The mean follow-up period was 4.6 ± 2.7 years. There was a significant difference between the TAP and nTAP Groups in TR improvement (93.6% vs. 67.3% respectively, p <0.001) and in change of TR grade (-2.1 ± 1.0 vs. -0.9 ± 1.0 respectively, p <0.001). Univariate analysis in the nTAP Group identified rheumatic etiology, atrial fibrillation, mitral stenosis (MS), and large left atrium prior to surgery as risk factors for failure of improvement. In multivariate analysis atrial fibrillation was identified as a predictor of failure of improvement (p = 0.004). CONCLUSION: Our results suggest that TAP should be performed concurrently with mitral valve surgery in patients with secondary TR of grade ≥2+, especially those having atrial fibrillation, even if TR is not severe.

Surgical experience with chronic constrictive pericarditis.

OBJECTIVE: Constrictive pericarditis is a disease characterized by marked thickening of the pericardium which causes restriction of diastolic cardiac function. The purpose of this report is to review the outcome of pericardiectomy for constrictive pericarditis and to discuss its problems. METHODS: Sixteen consecutive patients who underwent pericardiectomy for constrictive pericarditis in our institution between March 2000 and June 2011 were reviewed. All patients underwent decortication including at least the anterior surface from the right atrium to the left phrenic nerve and the diaphragmatic surface of the heart. The epicardium was concomitantly resectioned because it was usually sclerotic and constrictive. RESULTS: Postoperatively, mean central venous pressure decreased to 8.8 ± 3.1 mmHg and was significantly lower than the preoperative value 15.3 ± 3.7 mmHg (p < 0.001). The mean postoperative duration of hospitalization was 25.6 ± 13.5 days. There were 2 in-hospital deaths and early mortality rate was 12.5 %; however, excluding hospital deaths, there were no significant postoperative complications and all survivors recovered and maintained good cardiac function during the mean follow-up period of 3.7 ± 2.8 years. CONCLUSION: For an acceptable outcome, surgical intervention should be performed at an appropriate time and the pericardiectomy should have proper scope and depth to prevent irreversible changes in the heart, liver, and other organs.

Twelve years of experience with the ATS mechanical heart valve prostheses.

OBJECTIVE: The ATS Open Pivot mechanical heart valve has been implanted routinely at our institution since 1999. The objective of this study is to retrospectively analyze our 12-year clinical results with ATS prostheses. METHODS: ATS Open Pivot mechanical valves were implanted in 268 adult patients between May 1999 and August 2010. We selected 259 subjects who could be adequately followed (follow-up rate 96.6 %). Aortic valve replacement was performed in 157 patients, mitral valve replacement (MVR) in 71, and double (aortic and mitral) valve replacements (DVR) in 31. Mean age at the time of implant was 58.8 ± 10.6 years. The gender ratio was 128 males/131 females. Mean follow-up was 4.4 ± 7.8 years, and the cumulative follow-up was 1144 patient-years (pt-yr). RESULTS: Early death within 30 days after the operation occurred in 5 (2.5 %) patients. Late death occurred in 27 patients including valve-related deaths in 13. The 10-year survival rate after the operation was 82.7 ± 2.9 %. The rate of freedom from valve-related death was 92.2 ± 2.2 %. The incidence of valve-related complications was 2.19 %/pt-yr. Of these, the incidence of thromboembolic events and that of bleeding complications were 1.22 and that 0.87 %/pt-yr. The incidence of valve thrombosis was 0.09 %/pt-yr. No structural valve deterioration was observed in any of the three operative procedure groups. CONCLUSIONS: Our 12-year experience with aortic and MVR using the ATS mechanical heart valve demonstrated low incidences of thromboembolic events, bleeding complications, and valve thrombosis.

Time-dependent change in fresh autologous pericardium applied for posterior mitral annuloplasty: degree of calcification and its influence on the repaired mitral valve.

OBJECTIVE: To investigate the degree of calcification of fresh autologous pericardium applied for posterior mitral annuloplasty and its influence on the repaired mitral valve. METHODS: Thirty-nine patients (31 degenerative and 8 infective endocarditis; mean age at surgery: 62 ± 11 years) were enrolled in this study. Sixteen-slice multi-detector computed tomography was performed to identify calcification of autologous pericardium. The mean clinical follow-up was 4.6 ± 2.6 years (maximum 8.8 years) and the mean computed tomography follow-up period was 3.6 ± 2.5 years (maximum 7.6 years) after surgery. RESULTS: Pericardial calcification was detected in 15 patients. The earliest detection of calcification was 2.5 years after surgery. There was a weak correlation between pericardial calcification and postoperative years (Pearson's product correlation coefficient: 0.476; p = 0.0019). However, severe calcification of autologous pericardium did not occur in any case. There was no association between pericardial calcification and recurrent mitral regurgitation (p = 0.1145). The mean mitral valve orifice area and the mean transmitral pressure gradient in the 15 patients with calcification were 3.0 ± 0.6 cm(2) and 2.1 ± 1.0 mmHg, respectively. CONCLUSIONS: Calcification of the fresh autologous pericardium increased with postoperative years. It had no adverse effects on repaired mitral valve in the short-term follow-up period. We will report the findings once again when the follow-up reaches 10 years.