Mid-term outcomes of surgical aortic valve replacement using a mosaic porcine bioprosthesis with concomitant mitral valve repair.

This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75 years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.

Clinical impact of aortic valve replacement in patients with moderate mixed aortic valve disease.

Background: Information is scarce regarding the clinical implications of aortic valve replacement (AVR) for patients suffering from moderate mixed aortic valve disease (MAVD), characterized by a combination of moderate aortic stenosis (AS) and regurgitation (AR). The objective of this retrospective study was to explore the clinical effects of AVR in individuals with moderate MAVD. Methods: We examined the clinical data from patients with moderate MAVD and preserved left ventricular ejection fraction, who had undergone echocardiography in the period spanning from 2010 to 2018. Moderate AS was defined as aortic valve area index of 0.60-0.85 cm2/m2 and peak velocity of 3.0-4.0 m/s. Moderate AR was defined as a vena contracta width of 3.0-6.0 mm. The primary endpoint was a composite of all-cause death and heart failure hospitalization. Results: Among 88 patients (mean age, 74.4 ± 6.8 years; 48.9%, men), 44 (50.0%) required AVR during a median follow-up period of 3.3 years (interquartile range, 0.5-4.9). Mean values of specific aortic valve variables are as follows: aortic valve area index, 0.64 ± 0.04 cm2/m2; peak velocity, 3.40 ± 0.30 m/s; and vena contracta width, 4.1 ± 0.7 mm. The primary endpoint occurred in 32 (36.4%) patients during a median follow-up duration of 5.3 years (interquartile range, 3.2-8.0). Multivariable analysis revealed that AVR was significantly associated with the endpoint (hazard ratio, 0.248; 95% confidence interval, 0.107-0.579; p = 0.001) after adjusting for age, B-type natriuretic peptide, and the Charlson comorbidity index. Patients who underwent AVR during follow-up had significantly lower incidence rates of the endpoint than those managed with medical treatment (10.2% vs. 44.1% at 5 years; p < 0.001). Conclusions: Approximately half of the patients diagnosed with moderate MAVD eventually necessitated AVR throughout the period of observation, leading to positive clinical results. Vigilant tracking of these patients and watchful monitoring for signs requiring AVR during this time frame are essential.

Long-Term Outcomes of the Mosaic Mitral Porcine Bioprosthesis in Japan　- Results From the Japan Mosaic Valve Long-Term Multicenter Study.

BACKGROUND: This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic mitral porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:The medical records of 390 patients who underwent mitral valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014) were reviewed. Patient data were collected using the Research Electronic Data Capture software. Patient survival was determined using the Kaplan-Meier method. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined using actuarial methods. The median (interquartile range [IQR]) age of the cohort was 73 (69-77) years. The median (IQR) follow-up period was 4.83 (1.84-8.26) years. The longest follow-up period was 15.8 years. The 30-day mortality rate was 5.4%. The 12-year actuarial survival rate was 54.1±4.5%, and the freedom from valve-related death was 85.3±3.4%. The freedom from reoperation at 12 years was 74.3±5.7%. The freedom from SVD at 12 years was 81.4±6.6% for patients aged ≥65 years and 71.6±11.1% for those aged <65 years. The median (IQR) mean pressure gradient was 4.1 (3.0-6.0) and 5.6 (4.0-6.7) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.7 (1.4-2.0) and 1.4 (1.2-1.6) cm2at 1 and 10 years, respectively. CONCLUSIONS: The Mosaic porcine bioprosthesis offered satisfactory long-term outcomes for up to 12 years.

Usefulness of velocity ratio in patients with moderate aortic stenosis and reduced left ventricular ejection fraction.

Background. Moderate aortic stenosis (AS) increases left ventricular afterload and results in unfavorable outcomes in patients with reduced left ventricular ejection fraction (LVEF). Velocity ratio (VR) may be appropriate for the evaluation of aortic valve (AV) hemodynamics because of the low dependence on flow. Therefore, this study investigated the usefulness of VR on the clinical outcomes of such patients. Method. Clinical data of patients with moderate AS (AV area, 0.60-0.85 cm2/m2; peak AV velocity, 2.0-4.0 m/s) and reduced LVEF (LVEF 20-50%) were analyzed during 2010-2018. VR was calculated as peak left ventricular outflow tract velocity/peak AV velocity. The primary endpoint included all-cause death, heart failure hospitalization, and AV replacement. Results. In total, 104 patients (mean age, 75.9 ± 7.0 years; 62.5% men) were included. LVEF was 39.5% ± 7.8%. The AV area was 0.72 ± 0.08 cm2/m2, peak AV velocity was 2.59 ± 0.40 m/s, and VR was 0.30 ± 0.07. The follow-up period was 1.7 (0.5-3.5) years. Kaplan-Meier estimates for the endpoint were 59.9% at 3 years. Multivariable analysis revealed that VR (hazard ratio, 0.947; 95% confidence interval, 0.905-0.990; p = .018) was significantly related to this endpoint. Patients with a VR <0.25 had significantly higher incidence rates of the endpoint than those with a VR ≥0.25 (85.6% versus 47.8% at 3 years; p < .001). Conclusions. Patients with moderate AS and reduced LVEF have unfavorable clinical outcomes, particularly those with low VR.

Coronary sinus atrial septal defects in adults over the past 20 years at new Tokyo hospital: case series.

BACKGROUND: An isolated coronary sinus (CS) atrial septal defect (ASD) is defined as a CS unroofed in the terminal portion without a persistent left superior vena cava or other anomalies. This defect is rare and part of the wide spectrum of unroofed CS syndrome (URCS). Recently, several reports have described this finding. The database of New Tokyo Hospital was searched to determine the incidence of this defect. Additionally, to raise awareness of this condition, the findings from five patients with CS ASD who underwent surgical repair at New Tokyo Hospital are discussed. CASE PRESENTATION: The patients were three women and two men with an age range of 63-77 years. All patients underwent transthoracic echocardiography and computed tomography, and one underwent magnetic resonance imaging. In two patients, the defect was found unexpectedly intraoperatively; left-to-right shunting was apparent in the other three patients preoperatively. The pulmonary-to-systemic blood flow ratio ranged from 1.42 to 3.1 following cardiac catheterization, and oxygen saturation step-up was seen on the right side of the heart. Valvular regurgitation was seen in 4/5 patients with different combinations and degrees of mitral, tricuspid, and aortic valve involvement. Right atrial and ventricular dilation were seen in 4/5 patients; three patients had left atrial dilation. Three patients experienced atrial fibrillation, and one of these also experienced paroxysmal ventricular contractions. All patients underwent surgical repair, and some underwent multiple procedures. One patient who had previously undergone kidney transplantation died approximately 1 year postoperatively; the remaining four patients are currently experiencing good activities of daily living without symptoms. CONCLUSIONS: CS ASD (Kirklin and Barratt-Boyes type IV URCS) comprised 1.3% of adult congenital heart surgeries and 0.07% of adult open-heart surgeries at New Tokyo Hospital from 1999 to 2019. At New Tokyo Hospital, cardiac surgery is performed mainly for patients with acquired cardiac disease, and CS ASD is rare. Early diagnosis is important, as well as early surgical repair in symptomatic patients, especially those with blood access shunts, which may overload the heart. The case of a poor prognosis in this series is noteworthy, as similar cases have not been reported previously.

The Impact of Aortic Valvular Calcium on Transcatheter Heart Valve Distortion.

OBJECTIVES: To investigate the relationship between the eccentric calcification of aortic valve and transcatheter heart valve (THV) distortion and the impact of THV distortion on echo parameters and clinical outcomes. BACKGROUND: The effects of eccentric calcification of the aortic valve on the THV distortion and the relationship between THV distortion and clinical impact were not fully understood. METHODS: Patients with symptomatic severe aortic stenosis who were undergoing THV implantation were enrolled. Patients underwent preprocedural, postprocedural multislice computed tomography (MSCT), and follow-up transthoracic echocardiogram (TTE). Delta calcium score (ΔCS) is defined as the difference between the maximum and minimal calcium scores of the three cusps, while valve distortion score (VDS) is defined as the difference between the longest and shortest stent frame, as obtained using MSCT. Patients were divided into two groups according to ΔCS: "noneccentric calcification group" and "eccentric calcification group." RESULTS: A total of 118 patients were enrolled (59 patients in noneccentric and 59 in eccentric calcification groups). VDS was significantly lower in the noneccentric calcification group than in the eccentric calcification group (1.31 ± 0.82 mm vs. 1.73 ± 0.76 mm, p=0.004). VDS was not associated with the degree of paravalvular leak (PVL) and aortic valvular mean pressure gradient (AVPG) at 30-day and 1-year follow-up TTE and the cumulative rates of all-cause death and rehospitalization at 2-year clinical follow-up. CONCLUSIONS: Eccentric valvular calcification was associated with longitudinal THV distortion. However, THV distortion was not associated with PVL, AVPG, and adverse clinical events during midterm follow-up.

Bronchovenous Fistula During Adult Cardiac Surgery: A Case Report.

Bronchovenous fistula (BVF) associated with adult cardiac surgery is a rarely reported life-threatening condition. We present a 75-year-old woman who developed a BVF during cardiac surgery. Dense adhesion in the pleural and pericardial cavities was noted. Restrictive pulmonary pathology required high airway pressure. Transesophageal echocardiography and hemoglobin measurement were helpful for the timely diagnosis of BVF, which was controlled by transection of the right upper pulmonary vein where a vent catheter had been inserted. Injuries around the cannulated site presumably initiated the BVF, which was worsened by high-pressure ventilation. Therefore, cannulation site might be a risk factor for BVF.

Long-Term Outcomes of the Mosaic Aortic Porcine Bioprosthesis in Japan　- Results From the Japan Mosaic Valve Long-Term Multicenter Study.

BACKGROUND: This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic aortic porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:We reviewed the records of 1,202 patients who underwent aortic valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014). Patient data were collected using Research Electronic Data Capture. Patient survival was determined by Kaplan-Meier methodology. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined by actuarial methods. The median (interquartile range [IQR]) age of the cohort was 76 (70-80) years. The median (IQR) follow-up period was 3.52 (1.71-5.35) years. The longest follow-up was 15.8 years. The 30-day mortality rate was 2.3%. The 12-year actuarial survival rate was 59.9±7.5%, and the freedom from valve-related death was 81.1±7.9%. The freedom from reoperation was 86.4±2.6% at 12 years. The freedom from SVD at 12 years was 93.5±2.9% for patients aged ≥65 years and 98.2±1.8% for those aged <65 years. The median (IQR) systolic pressure gradient was 17 (12-23) and 19 (12-25) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.2 (1.1-1.5) and 1.1 (1-1.5) cm2at 1 and 10 years, respectively. CONCLUSIONS: The Mosaic porcine bioprosthesis showed satisfactory long-term outcomes over 12 years.

Application of focused ion-beam sampling for sidewall-roughness measurement of free-standing sub-µm objects by atomic force microscopy.

In the present study, a free-standing object-sampling technique for microelectromechanical systems (MEMS) is developed to measure their sidewall surface roughnesses by atomic force microscopy (AFM). For this purpose, a conventional focused ion beam (FIB) sampling technique widely used for cross-sectional transmission electron microscope specimen preparation was applied. The sub-nm-order roughness parameters were quantitatively measured for sidewalls of Si-bridge test samples. The roughness parameters were compared before and after H2 annealing treatment, which induced smoothing of the surface by migration of the Si atoms. The reduction in the surface roughness by a factor of approximately one-third with 60-s H2 annealing was quantitatively evaluated by AFM. The present study confirms that the developed FIB-AFM technique is one potential approach for quantitatively evaluating the surface-roughness parameters on the oblique faces of free-standing objects in MEMS devices.

Hemodynamic Performance and Outcomes of Mosaic Valve for Aortic Stenosis with Decreased Left Ventricular Function: Results from J-MOVE Study.

We evaluated impact of a small-sized Mosaic porcine bioprosthesis on hemodynamic performance and outcomes in patients with aortic stenosis (AS) and low left ventricular ejection fraction (LVEF) in a Japan multicenter cohort. Of 1,202 patients enrolled, 105 (8.7%) who had LVEF < 50% and AS underwent aortic valve replacement (AVR). Fifty-two patients received Mosaic porcine bioprosthesis ≤ 21 mm (S-AVR), and 53 received a bioprosthesis ≥ 23 mm (L-AVR). The median follow-up period was 3.1 [1.2, 5.1] years. At 5 years, LVEF significantly improved from median 41.2 [33.8, 45.9]% to 64.2 [49.8, 72.5]% in S-AVR (p < 0.001) and from median 43.2 [37.3, 46.8]% to 61.2 [47.2, 68.0]% in L-AVR (p < 0.001). The left ventricular mass index significantly decreased from median 158.4 [122.2, 194.9] to 110.0 [83.6, 129.4] gm/m in S-AVR (p < 0.001) and from median 169.8 [132.2, 203.6] to 109.6 [101.8, 132.4] gm/m in L-AVR (p < 0.001). There were no significant differences between S-AVR and L-AVR groups regarding freedom from cardiac death (93.1 ± 3.9% vs. 96.2 ± 3.8%; p = 0.119) and valve-related death (97.6 ± 2.4% vs. 100.0 ± 0.0%; p = 0.953). Clinical outcomes and improved hemodynamic performance were similar in both groups.

Risk score system for late aortic events in patients with uncomplicated type B aortic dissection.

OBJECTIVE: Several risk factors for late aortic events in patients with uncomplicated type B aortic dissection (UTBAD) have been reported; however, they remain controversial. We developed and validated a new risk prediction score system for late aortic events in patients with UTBAD. METHODS: We reviewed 187 consecutive patients diagnosed with UTBAD from 2004 to 2017 at 2 centers (derivation cohort) and 219 consecutive patients diagnosed with UTBAD from 2012 to 2016 in 4 other centers (validation cohort). We explored predictors of late aortic events using Fine-Gray generalization of the proportional hazards model, then developed a risk prediction score model and determined the test reliability using time-dependent receiver operating characteristic analyses. Finally, we validated the model using external multicenter data. RESULTS: The risk prediction score system was developed using the following independent predictors: initial aortic diameter of ≥40 mm (2 points), false lumen diameter larger than true lumen diameter (2 points), ulcer-like projection (1 point), and age ≥70 years (1 point). Receiver operating characteristic analysis showed that a cut-off total additive score of 2 points. In the validation cohort, the low-risk group (score, 0-1 point) demonstrated lower 1- and 3-year incidence rates of late aortic events than the high-risk group (score, 2-6 points) (0.9% vs 32.5% and 0.9% vs 47.1%, respectively; P < .0001). CONCLUSIONS: We developed a simple risk prediction score system for late aortic events in patients with UTBAD. High-risk patients can be identified using our model, and they should be closely monitored and considered for interventions at the appropriate timing.

Long-standing persistent effects of atrial volume reduction combined with pulmonary vein isolation.

Although surgical left atrial (LA) volume reduction combined with mitral valve surgery and/or surgical ablation for atrial fibrillation has been reported to be effective, its long-term outcomes in the absence of mitral procedure are not well established. A 74-year-old man with two previous sternotomies-the first for pericardiectomy due to constrictive pericarditis and the second for mitral valve replacement with mechanical valve and tricuspid annuloplasty-presented with heart failure and thrombus in his giant left atrium (1291 mL), complicated by cerebral infarction. His electrocardiogram showed rate-controlled persistent atrial fibrillation. His mechanical valve was functioning well. A third atrial volume reduction combined with pulmonary vein isolation, without valve surgery, was performed. The postoperative course was uneventful, and the patient has remained asymptomatic with regular junctional rhythm and without any episodes of thromboembolism or re-dilation of LA (approximately 550 mL). His left ventricular filling improved with end-diastolic volume (96 mL vs 140 mL) and forced vital capacity (2.60 L vs 2.89 L) increased. Both remained relatively constant for 6 years. The combination of atrial volume reduction with pulmonary vein isolation prevented thromboembolism, improved left ventricular filling, and continued to improve symptoms associated with heart failure and respiratory condition for 6 years. .

ST-segment elevation myocardial infarction caused by aortic pseudoaneurysm following surgical mitral valvuloplasty.

Pseudoaneurysm is one of the complications after arterial cannulation. We report the case of a patient with ST-segment elevation myocardial infarction due to aortic pseudoaneurysm after surgical mitralvalvuloplasty. Careful evaluation should be performed in cases of ST-segment elevation myocardial infarction following cardiac surgery, even after several months.

Transcatheter Balloon Expandable Aortic Valve Implantation through an Aortofemoral Bypass Graft.

An 84-year-old woman was diagnosed with symptomatic severe aortic stenosis. She had previously undergone aortobifemoral bypass grafting (Y graft) for bilateral iliac stenosis. In view of a high surgical risk, a decision for transcatheter aortic valve implantation (TAVI) was made. An incision was made on the right limb of the Y graft and subsequently a 16 Fr e-sheath was smoothly advanced through the graft. A 23 mm balloon expandable valve was then advanced with no resistance and successfully deployed. This case highlights the feasibility of TAVI through the graft, but requires a thorough preprocedural assessment of the access route using multiple imaging modalities.

A Calcified Amorphous Tumor Originating in the Sinus of Valsalva.

An 81-year-old male with end-stage renal disease undergoing hemodialysis was admitted to our hospital for congestive heart failure secondary to severe aortic stenosis. Transesophageal echocardiography revealed a 15.3 × 9.9 mm calcified mass in the sinus of Valsalva. The tumor was diagnosed as a calcified amorphous tumor (CAT) by histologic examination. This is the first report of a CAT that originated in the sinus of Valsalva.

Successful Repair of Regurgitant Pentacuspid Pulmonary Valve Combined With Pulmonary Artery Aneurysm.

Pentacuspid pulmonary valve is an extremely rare congenital anomaly. A 71-year-old woman presented with dyspnea on exertion. The preoperative examination showed a large pulmonary artery aneurysm with severe pulmonary regurgitation. The pentacuspid pulmonary valve was an intraoperative finding with four equivalent leaflets and one hypoplastic leaflet. The valve was successfully repaired by use of a bicuspidization technique combined with annuloplasty, and pulmonary artery reduction was performed. Postoperatively, the patient remained asymptomatic with trivial pulmonary regurgitation 1 year later. To our knowledge, this is the first report of a pentacuspid pulmonary valve repair.

Calcified amorphous tumor of the left atrial appendage.

A 57-year-old female with end-stage renal dysfunction was admitted to our hospital. The echocardiogram revealed a 9mm×22mm hyperechoic mass in the left atrial appendage (LAA). The mass was extremely mobile. Considering the high risk of embolic events, we decided on a surgical resection. Microscopic examination of the mass revealed a nodular focus of calcification and fibrosis with focal chronic inflammation of the atrial endocardium. The endocardium was uniformly thickened with no evidence of neoplastic proliferation. The mass was diagnosed with a calcified amorphous tumor (CAT). This is first report of CAT of the LAA.